Fill - Free fillable New- Patient- Form-2020 - New Patient Forms 2017 PDF form



ERSTONETH

ERAPYAND

WELLNESS

(610)616‐5935



639SwedesfordRoad

Malvern



19355



996OldEagleSchoolRoad,Suite1105,Wayne,PA19087







LAST NAME:

FIRST NAME:

MIDDLE INITIAL:

ADDRESS:

CITY:

STATE:

ZIP:

GENDER: Male Female

MARITAL STATUS:

Single Married Partner

Divorced Separated OTHER

PHONE:

WORK PHONE: CELL PHONE:

DATE OF BIRTH:

CONTACT E-MAIL:

WHO REFERRED YOU TO

Cornerstone Therapy and Wellness, LLC?

PATIENT EMPLOYER INFORMATION: Employed Student OTHER

COMPANY/SCHOOL:

OCCUPATION:

SAME AS ABOVE

LAST NAME: _ FIRST NAME: MIDDLE INITIAL:

ADDRESS: CITY:

_ STATE: ZIP:

GENDER:  Male  Female MARITAL STATUS:  Single  Married  Partner  Divorced  Separated  OTHER _

PHONE: _ WORK PHONE: _ CELL PHONE:

DATE OF BIRTH:

RELATIONSHIP TO THE PATIENT:

EMPLOYER INFORMATION:



Employed



Student



OTHER

CONTACT E-MAIL

COMPANY/SCHOOL: _

OCCUPATION: _

INSURANCE COMPANY:

INSURANCE ID # OF PATIENT:

INSURANCE CO PHONE: _ COPAY:

EMERGENCY CONTACT NAME:

PHONE NUMBER:

IN ORDER TO FILE YOUR INSURANCE FOR YOU, WE REQUIRE THAT YOU CHECK EACH BOX AND

SIGN THE FOLLOWING SIGNATURE-ON-FILE FORM. (Including EAP)

I authorize release of my information and claim submissions to all my insurance carriers.

I unde rstand that I am responsible for my or de pe nde nts bill and it is my responsi bility to confirm my

coverage and be ne fi ts. For any reason the submitted claims are not paid within 45 days of the date of

service, I will become responsible for the entire bill.

I authorize

Cornerstone Therapy and Wellness

act as my agent in helping me obtain

payment from my insurance carriers.

I hereby authorize payment directly to Cornerstone Therapy and Wellness, if any, otherwise

payable to me for their se rvi ces as describe d, realizing I am responsible to pay non-c overed services.

Signature: ____________________________________________________________________ Date:

|Pag e

URAN

ZAT

PRIM

ORM

TION

RESPONSIBLE PARTY

INFORMATIO

NEW

CLIENT

INFORMATION

FORM

(Please

Print)

click to sign

signature

click to edit



ERSTONETH

ERAPYAND

WELLNESS

(610)616‐5935



639SwedesfordRoad

Malvern



19355



996OldEagleSchoolRoad,Suite1105,Wayne,PA19087



I (Patient Name/Parent/Guardian) ________________________________________________, have read the

statement below and agree by the terms and conditions.

We will make your payment as easy and convenient as possible. You may pay your copay or

deductible by cash, check, credit card or debit card. We require a credit card on file to

supportthe

cancellation policy.

INITIAL:______

I understand that there is a 3% surcharge for every credit/debit card transaction.



Exp. Date:Credit Card/Debit Card #: xxxx xxxx xxxx ________________ (Last 4 #’s)



Card Type:

Visa / MasterCard / Discover

(circle one)

INITIAL: _____

I understand that a 24 hr notice is needed

for any cancellations or I will be billed the

following fees:

Therapy:

Psychiatry Med Check:

Psychiatry Evaluation:

$50.00

$75.00

$180.00

This is not a

billable charge

to your insurance

company. All

cancellations need to be

made

phone. I also understand that there will be a $30.00 charge for all returned checks.

I authorize Cornerstone Therapy and Wellness to charge my co pay, outstanding balances and/or

cancellation fee charged on my account to the provided credit card number/debit card or any replacement

credit card that I supply during my treatment period. I also understand that any balance on my

account ultimately becomes my responsibility as

well as the primary insurance policy holders

Signature: ________________________________________________________________________ Date :

------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Credit card information

: (

this section will be detached and destroyed once entered into our (PCI DSS) compliant system

)



Credit/Debi t Card # ______________________________________Expiration Date: ______

/_______/

________



Name on Card: ______________________________________________Security Code: _____________



Card Type:

Visa / MasterCard / Discover

(circle one)

|Pag e

INAN

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signature

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CORNERSTONE



THERAPY



AND



WELLNESS



639SwedesfordRoad



LVER



19355



CON

T TO T

EATME

PRESCRIPTION

REFILLS:

(610)616‐5935

996OldEagleSchoolRoad,Suite1105,Wayne,PA19087



I authorize, request, consent and agree to receive treatment /services from Cornerstone Therapy and

Wellness. I understand that I can withdraw this consent to treatment at any time. A withdrawal of consent will

be done in writing and will include the reason for withdrawal.

I understand that the office doe s not handle any of the following: work grievances, lawsuits, custody disputes,

disability determinati ons, or any other legal admi nistrati ve proceedings, including work excuses and request

for change in job con diti ons.

As the policy holder and/or patient fully understand that I am directly responsible for payment to C o r n e r s t o n e T h e r a p y

and Wellness for the entire services rendered to me. I also understand that my insurance is an

agreement between me and my insurance company. As a courtesy, Cornerstone Therapy and Wellness,

will file your insurance claims for me. For any reason, the submitted claims are not paid to them within 45 days

of the date of service, the policy holder and/or patient will become responsible for the entire bill. If such

an event does arise, an itemized bill will be given to me to help process my claims. This is a standard

practice within the Mental Health Industry.

I understand there is a fee for a copy of my record if the request comes from anyone other than another state

licensed physician or mental health practitioner. (M.D., LCSW, PsyD, LPC, etc.) This fee is outlined and

regulated by the PA Department of Health and is available on their web site. (www.health.pa.gov)

I understand that my physician will give me adequate prescriptions until my next scheduled visit and that is

my responsibility as the patient to make the next appointment in the correct time frame to be able to refill my

prescription. I also fully understand no refills will be given if I have not seen my physician within 90 days of

my last appointment. I also understand no re fi lls will be processed if I have missed or cancelled more than

one appointment. I understand that the office does not mail in prescriptions. I also understand controlled

substances prescriptions will not be replaced if lost or stolen

By my signature below, I acknowledge that I have read, understood and agree to all the above.

Signature: ________________________________________________________________________ Date:

/________/

|Pag e

FEES

FOR

ADDITION AL

SERVICES:

GUARANTEE

AYM

ENT:

F P

KNOWLEDGEMENT

EIPT:

read, review

and understand the documents fully.

Policy"

and"Teletherapy Informed Consent"

documents

and confirm that I

have had adequate opportunity to

Notice,"

"Financial Policy,"

"Electronic Communication Agreement,"

"Patients’ Rights and Responsibilities

I acknowledge that I have received from Cornerstone Therapy and Wellness, the

"Federal HIPAA Privacy

click to sign

signature

click to edit

CORNERSTONE



THERAPY



AND



WELLNESS

(610)616‐5935



639SwedesfordRoad,Malvern,PA19355

996OldEagleSchoolRoad,Suite1105,Wayne,PA19087



Reason for this policy:

To be effective, counseling and psychotherapy need to take place on a regular basis. The best

results occur when appointments are consistently scheduled and attended regularly. Additionally, an

appointment time reserved for you means that it cannot be used for someone else. It is reserved for

you and/or your family.

If the policy holder and/or patient do not notify your Therapist/Psychiatrist by phone of your

intention to cancel or reschedule 24hrs in advance, you will be charged the following fees:

Therapy: Psychiatry Med Check: Psychiatry Evaluation:

$50.00 $75.00 $180.00

Cancelling or re-scheduling within 24hrs allows the therapist an opportunity to schedule

someone else for that time slot. This is important because others may be on a waiting list

for or preferred your time slot.

If you reschedule to a later time of the day or week of your scheduled appointment and if

there is an opening, the cancellation fee will be waived.

You will never be charged for a cancellati on that is made more than 24 hours in advance of your

scheduled appointment time.

This cancellation policy is standard in the mental health field.

If you simply do not show up for a sche dule d appointment, you will be charged for the missed

appoi ntment.

This fee is

not

billable to your insurance company and is your out-of-pocket responsibi lity.

Arriving late without notification: Your therapist will wait for you for 15 minutes after which they

will assume you are not coming and may leave the office. In such a case, you will be charged for a

missed appoi ntment.

On occasion, there will be understandable reasons for missing appointments, but, exceptions to

this policy will be rare. In the e vent of illness or work emergency, a phone sessi on is an opti on. There

is no charge for missed appointments due to snow conditions or declared states of emergencies.

If you have questions about this cancellation policy, you should discuss this with your therapist at the

start of therapy. Please sign below to indicate you have read, understand, and agree to abide by our

cancellation policy. Thank you.

Signature:

Date:

|Pag e

Hour

Cancellation

Policy

click to sign

signature

click to edit

CORNERSTONE



THERAPY



AND



WELLNESS

(610)616‐5935



      

639SwedesfordRoad,Malvern,PA19355

996OldEagleSchoolRoad,Suite1105,Wayne,PA19087

This

not

request

for

patient

records.



Authorization

Disclose Personal

Health

Information

Primary

Car

Physicia

PATIENT INFORMATION:

LAST:

FIRST:

MI:

BIRTHDATE:

DATE:

PRMARY

ARE

PROVIDE

INFORMATION

PHYSICIAN/PRACTICE NAME:

PHONE:

FAX:

ADDRESS CITY/STAT E/ZIP

MENTAL HEALTH PROVIDER INFORMATION: (Information below to be completed by therapist or physician)

Dear Primary Care

Provider,

I am sending this form to notify you that I am currently seeing

your patient in a therapeutic setting and to provide our offices with

a release of information to facilitate communication and to

coordinate services in regards to client care. If further information is

desired, please contact me at your convenience.

This is NOT a

request for you to send us medical records.

MAILIN

G ADDRESS:

Cornerstone Thera

y and Wellness

639 Swedesford Road, Malvern, PA 19355

996 Old Eagle School Road, Suite 1105 Wayne, PA 19087

Phone: (610) 616-5935

Fax: (484) 318-7166

www.cornerstonetherap y.com

THERAPIST NAME (please print)

CLINICAL INFORMATION:

REASON FOR RELEASE:

DIAGNOSIS: MEDICATIONS:

REATMENT PLAN(S) OR

RECOMMENDATIONS:

CONSENT AND RELEASE:

I authorize the exchange of my personal health information (PHI) regarding my clinical care needed to

coordinate treatment with my primary care physician. I understand that my records are protected under the

Federal and specific State confidentiality laws and regulations and cannot be disclosed without my written

consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at

any time except to the extent that action has been taken in reliance on it and that this consent expires automatically

as described below. Information to be released includes diagnosis, treatment procedures and details of my

condition which help to coordinate treatment. I further acknowledge that the information to be released was

fully explained to me and this consent is given of my own free will. This release is valid for one year after last

contact and I may cancel it in writing at any time.

I Do Consent:

SIGNATURE(S): DATE:

I do not consent to th e rel eas e and exchange of any informati on regardi ng my cl ini cal

car e to my primary car e physi ci an.

I Do N ot Consent:

SIGNATURE(S):

DATE:



|Pag e

Directions:

Malvern Location: 639 Swedesford Road, Malvern, PA 19355

We are located in the Swedesford Corporate Center on the corner of Phoenixville Pike and Swedesford Road. As

soon as you pull in the parking lot off of Swedesford Road, our

entrance is located directly on the front left-hand

side of the building.

Wayne Location: 996 Old Eagle School Drive, Suite 1105, Wayne,

PA 19087

(When entering address in google maps, Waze or any other GPS device, please include the suite #)

Our entrace is located off of Devon Park Drive (Evolve West corporate center). As soon as you pull into the

parking lot drive past our building (996) and make a right after the first speed bump. Our entrance is the second

entrance on the right hand side. (Letter G and Suite 1105 located on outside glass door)

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