New Patient Registration

Patient Information:

Note: Please type name exactly as spelled on your insurance card

First Name *

Middle Name

Last Name *

Preferred Name

Address *

City *

State *

Zip *

Home Phone *

Cell Phone *

Email

Date of Birth * +

Age *

SSN

Gender *

Identifies as *

Marital Status *

Ethnicity *

Primary Language *

Interpreter Needed? *

Yes

No

Employer

Occupation

Employer Phone Number

Employer Address

Emergency Contact

Emergency Contact Name *

Relationship to Patient *

Emergency Contact Address

Contact Phone Number *

Parent(s)/Guardian(s)/Spouse

Note: If divorced, please supply Pearl Health Clinic with legal documentation of custody to ensure that privacy rights can be followed.

Is there a custody arrangement for your child? *

Yes

No

If yes, please describe:

Full Name

Date of Birth +

SSN

Address

City

State

Zip

Home Phone

Cell Phone

Employer

Employer Phone

Full Name

DOB +

SSN

Address

City

State

Zip

Home Phone

Cell Phone

Employer

Employer Phone

Please check the box and initial, if it is ok to communicate with you regarding the following via...

Appointment Message

Clinical Message

Financial Message

Medical Information

**Please note that Case Managers should accompany developmentally or severely mentally ill clients.**

Patient's Primary Care Physician

Physician Phone Number

Most recent visit +

Pharmacy

Pharmacy Address

Pharmacy Phone

Medical History (High Blood Pressure, Diabetes, Asthma, Cancer, Heart Disease) *

Surgical History *

None	Explained Below

Surgical History Explained

Medication Allergies *

None	Explained Below

Medication Allergies Explained

Current Prescription Medication *

None	Explained Below

Current Prescription Medication

Over the Counter Medications *

Social History

Family History *

Smoke? *

Yes

No

If yes, how many packs per day?

How many years?

Alcohol? *

Yes

No

If yes, how much?

If receiving mental health service from another facility, please list them below

Location

Case Manager Phone Number

Services

Reason for being seen at pearl *

Name of Referring Provider

Services Requested--Please check all services that the patient is interested in.

Is there a specific medical provider or counselor you would like to request to see?

What to expect on your first appointment

Children 17 and younger need to be accompanied by a Parent and / or Legal Guardian. **NO EXCEPTIONS**
Please arrive 15 minutes prior for new patient appointments.

New Patients will be scheduled for a Comprehensive Diagnostic Assessment (CDA) which is approximately 1 ½ hours in duration, with a Licensed Mental Health Counselor. This appointment is a set of evaluation procedures administered to obtain information about the person’s development, learning, memory, academics, behavior, and mental health. This assessment is vital in allowing your provider(s) the ability to establish an accurate treatment plan

Legal Services Disclaimer

Pearl Health Clinic staff does not complete parental fitness or custody exams. Assessments for legal purposes are typically not covered by most insurance companies and are associated with a fee schedule separate from the mental health fee schedule. All requests for services in legal contexts will be reviewed and may be declined at discretion of the Pearl Health Clinic Clinical Director or individual clinicians. Pearl Health Clinic staff charge for any testimony provided in a legal context, even when original services were rendered as part of mental health treatment.

Initial *

Appointment Cancelation/No Show Policy

Effective 1/1/2023, any client who cancels an appointment within 3 hours of the scheduled appointment or fails to arrive within 15 minutes of the appointment time is considered a “no-show.” If you do not cancel or reschedule your appointment with at least 3-hour notice, we may assess a $25.00 “No Show” service charge to your account. This “No Show charge” is not reimbursable by your insurance company. You will be billed directly for it. After three (3) consecutive No Shows, Pearl Health Clinic may decide to end its relationship with you and you will need to transfer care to another provider.

Initial *

Consent for Student to attend appointment. (Please select one)

Yes, I give consent for student to participate in my appointment.

No, I do not give consent for student to participate in my appointment.

How did you hear about Pearl Health Clinic? (Please select one.)

Preferred Location (Please select one.)

Ammon Location

Idaho Falls Location

Pocatello Location

Rexburg Location

Printed Name of Patient or Parent/Guardian of Patient (if under 18 years of age) *

Relation *

Signature of Patient or Parent/Gaurdian of Patient *

clear

Date * +

Insurance Information and Authorization to Bill Insurance

Insurance Information

Patient Name

Date of Birth +

Primary Insurance

Insurance Policy Number

Insurance Group Number

Policy Holder

Phone

Relationship to Patient

Date of Birth +

SSN

Policy Holder's Address

Employer

Employer Phone

Secondary Insurance

Insurance Policy Number

Insurance Group Number

Policy Holder

Phone

Date of Birth +

SSN

Relationship to Patient

Employer

Employer Phone

Policy Holder's Address

**If you are concerned about the cost of services at Pearl Health Clinic, please contact our Billing Office directly to discuss payment options. To apply for a Sliding Scale, a discount applied to your const of services based upon your family size and income compared to the Federal Poverty Guidelines, please go to our website at https://pearlhealth.org/clients/financial-assistance/ and complete the Sliding Scale Application or speak with our Billing Office for Assistance.**

Release to Bill Insurance for Service and Release to Bill Insurance for Service

PHC is a contracting provider with most insurance carriers, and we will bill your insurance accordingly. We will do everything we can to aid you in receiving the maximum allowable benefits from your insurance carrier; however, you are ultimately responsible for your account. This includes any unpaid balances, after contractual adjustments (if applicable). Providing PHC with current and accurate insurance information will allow us to obtain the quickest response from your insurance. Your insurance may not cover services at the same rates as other participating providers. Some insurance plans require that the patient contact them for Prior Authorization. Failure to contact them, as required, may result in you being responsible for the full amount of your charges.
For Minor Patients or those with Legal Guardians: The Parent/Guardian and/or Guarantor is responsible for the payment (and all balances due), at the time of treatment. Unaccompanied Minors MUST have pre-authorization, from the Parent/Guardian. Please note that statements will only be sent to the Responsible Party, as indicated on the Patient’s Intake. If you have a credit balance, a refund check will be issued to you immediately. *For plan Specific information, please contact your insurance carrier, directly.

Assignment and Release

Non-Medicare: I hereby assign my insurance benefits, to be paid directly to Pearl Health Clinic. I understand that I am financially responsible for any non-covered services (including those with MEDICAID). I also authorize Pearl Health clinic to release any information required to process my claims.

Medicare/Medicare Advantage Plans: I request the payment of authorized Medicare benefits to be made on my behalf to Pearl Health Clinic. This payment should include payments for services provided to me, by Pearl Health Clinic and its affiliate Providers. I authorize the release of my personal medical information, to the Centers for Medicare and Medicaid Service (CMS) and its agents. The release of said information shall be used to determine benefits or the benefits payable for related services. This authorization is effective until I choose to revoke it, in writing. Standard Medicare patients are required to sign an annual ABN notice.

Printed Name of Patient or Parent/Guardian (if under 18 years of age) *

Relationship to Patient *

Signature of Patient or Parent/Guardian of Patient *

clear

Date * +

Informed Consent

TO TREAT AND TO USE AND TO DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR TREATMENT

By signing this form, you agree to our “Notice of Privacy Practice”. The patient or parent/guardian consents and authorizes Pearl Health Clinic to provide treatment. Failure to sign this form will terminate all services provided at Pearl Health Clinic. This form constitutes an agreement between,

Patient Name *

and Pearl Health Clinic. Hereafter, the patient will be referred to as “you” or “your”.

Reason for Consent

Pearl Health Clinic is committed to providing the highest quality of care. For this reason, we coordinate care with your Primary Care Physicians, insurance provider, government entities, pharmacy databases, and others pertinent to your treatment. When we examine, diagnose, treat, or refer you to another provider, we will be collecting/sharing Protective Health Information (PHI) about you. This information is used to decide what treatment(s) are best for you and to provide treatment(s) to you. Understand that many treatment options provided at Pearl Health Clinic also require that we pre-authorize that service or treatment before we begin the specified treatment. Not having current and accurate information can delay those services or result in those services being denied. Policies and agreements highlighted in this informed consent, Primary Care Physician, Mandated reporting requirements, Client Rights, and Prescription History. Please refer to the “Notice of Privacy Practice” to get further detail or clarification. If you do not have a copy, you can obtain one with our Front Office Staff or online at www.pearlhealth.org. These policies are susceptible to change and as these changes occur, so may our “Notice of Privacy Practice”. Changes will be updated as needed.

Primary Care Physician

You consent to the exchange of your protected health information between Pearl Health Clinic and your Primary Care Physician (PCP).

PCP Name

PCP Phone Number

Mandated Reporting

Treatment providers and staff are mandated reporters. We are required by law to report a “reasonable suspicion” for threats of harm against yourself or others to the appropriate authorities and persons of interest.

Client Rights

You have the right to request Pearl Health Clinic and its staff to not disclose information regarding treatment, payment, and/or administrative purposes. Requests must be made in writing with dates and signatures. PHC will make every effort to respect your requests, however, PHC retains the right to determine the appropriateness of the requests as PHC is compelled to follow HIPAA laws as well as other state and federal regulations. Processing claims and mandated reporting requirements are examples of requests that will be rejected. You have the right to revoke this consent at any time. This must be submitted in writing and will be processed through the Reception Staff. Disclosure of your information will cease, effective the date of the letter revoking consent. Any information disclosed on or before revoking consent, cannot be changed. Please keep in mind that revoking this request may limit the effectiveness of treatment and/or disrupt treatment.

Prescription History

By signing this form, you agree to the access/review of your external prescriptions history obtained from local and national pharmacy databases. Use of this information is used internally for your healthcare and will not be released without your consent, unless deemed medically necessary.

I understand that if I am the custodial parent or guardian, medical record information will be released only upon my request. You may sign and complete a written “Release of Information” (ROI), which will be maintained on file with Pearl Health Clinic. This release shall indicate who this information shall be disclosed to. Please note that non-custodial parents or guardians with appropriate legal documentation shall have access to these records, regardless of if there is a release on file.

I authorize Pearl Health Clinic to be able to speak with the following people regarding my medical information:

Name

Relation

Name

Relation

Printed Name of Patient or Parent/Guardian (if under 18 years of age) *

Relation *

Signature of Patient or Parent/Gaurdian of Patient *

clear

Date * +

Notice of Privacy Practices

Notice of Privacy Practice is available upon request via email *

I request a digital copy of the "Notice of Privacy Practice"

I do not request a digital copy of the "Notice of Privacy Practice" currently

Email Address *

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