New Patient Bundle – Karen C. Truesdell, PhD

Welcome!

Please fill out the new patient intake form below.

Once completed it will redirect you to the scheduling portal to setup your initial consultation.

I look forward to meeting you soon!

New Patient Form 2022

Name:(Required)

First Last

DOB:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone:

Cell Phone:(Required)

Social Security Number:(Required)

Email:(Required)

Driver's License Number:(Required)

State Issued:(Required)

Place of Employment:(Required)

Job Title:(Required)

Business Phone:

Name of Spouse/Partner (Guardian of Child):

Date of Birth:

Place of Employment:

Job Title:

In Case of Emergency, Who Should We Contact?(Required)

Phone:(Required)

Relationship to Patient:(Required)

Party Responsible:(Required)

Referred By:

Medications:

Purpose:

INSURANCE INFORMATION:(Required)

Dr. Truesdell Bierman does not bill any health insurance. Should you wish to submit for your out of network benefits, the Office will provide a Super Bill. There are many reasons people choose not to use their insurance to pay for mental health services. Please note that if you have insurance and choose not to use it at this time, we cannot submit claims for prior services at a later date should you change your mind about using insurance. If you choose not to use health insurance to pay for services, please check appropriate box below:

I do not have health insurance and will be paying for professional services directly.

I do have health insurance but am choosing not to file any claims for benefits related to these services.

PRIMARY CARE PHYSICIAN:

Physician Phone Number:

AUTHORIZATION AND RELEASE:(Required)

I hereby authorize the clinician to release all information necessary to secure payment of benefits from my insurance company. I authorize the use of this signature on all my insurance submissions whether manual or electronic. I fully understand that I am financially responsible for all charges whether or not paid by the insurance company.

Full Name

STATEMENT OF UNDERSTANDING / CONSENT:

Confidentiality:

Confidentiality: You have the right to confidentiality in your therapy. Information concerning your therapy will not be disclosed without your prior written permission except for the following legal exceptions: 1. Life or safety of you or someone else is seriously threatened. 2. There is good reason to believe that you are abusing or neglecting a child or vulnerable adult or if you give me information about someone else who is doing this, child/adult protective services and/or the appropriate law enforcement agency must be notified. 3. Court ordered treatment. 4. An insurance benefit is filed and the claims payer requires information, i.e. diagnosis, types of treatment, dates. 5. I have the right to report animal cruelty to appropriate authorities.

Emergencies/Telephone Counseling:

Emergencies/Telephone Counseling: Medical and/or psychiatric emergencies should be directed to 911 if life or safety is threatened. I will return your call as soon as possible during regular working hours and no later than the next working day. Emergency calls and telephone counseling are not covered by insurance. After hours and the weekend, please leave a message and I will get back to you on the next business day. If I cannot be reached and this is a life-threatening emergency, please go to the nearest ER; do not wait for me to return your call. Scheduling of Appointments: Please conscientiously keep all scheduled appointments. If it is necessary to cancel an appointment, you must give at least 48 hours notice. Monday appointments must be canceled before noon on the preceding Friday. You will be charged $150 for missed appointments or appointments canceled without 48 hours advanced notice. If you do not show up for two scheduled appointments, then you will not be allowed to schedule future appointments. Insurance companies DO NOT pay for missed appointments. Exceptions to this policy may be made for unforeseen emergencies, but must be discussed on a per case basis with the therapist. If you miss an appointment and do not contact the office about the reason, your next appointment is automatically cancelled. If you arrive more than 15 minutes late for your appointment, your session cannot be extended into the next client’s time; therefore, you will be charged as a missed appointment ($150). Insurance companies will not pay for sessions less than 45 minutes). Fee Policy: While the filing of insurance claims is a courtesy that is extended to you, all charges are ultimately your responsibility for the date of service. All co-payments, unmet deductible expenses, and services or charges not covered by insurance are due at the time of service. Any returned checks are subject to a $25 charge. Those who have out-of-network benefits must pay the full fee upfront and have the insurance company reimburse them. Should your account be referred for collections, you agree to pay 6% interest plus a $25 collection fee and reasonable attorney fees and/or court costs. Fees for Services: I provide therapy for the fee of $225 per 50 minute session. I charge $225 per hour for reports, letters, and other documentation. Any services I provide beyond your therapy session, or what your insurance company has authorized, are charged to you directly at my hourly rate of $225 (charged in 15-minute increments), to include phone calls exceeding five minutes. Court appearances begin at $250 per hour. Fees for other services provided upon request. Consent for Care: I give full consent for the completion of my evaluation and provision of treatment as necessary, by the above named provider, until otherwise notified. If I have any questions about the following information or about anything related to my case, I will discuss this with Dr. Truesdell Bierman.

Scheduling of Appointments:

Scheduling of Appointments: Please conscientiously keep all scheduled appointments. If it is necessary to cancel an appointment, you must give at least 48 hours notice. Monday appointments must be canceled before noon on the preceding Friday. You will be charged $150 for missed appointments or appointments canceled without 48 hours advanced notice. If you do not show up for two scheduled appointments, then you will not be allowed to schedule future appointments. Insurance companies DO NOT pay for missed appointments. Exceptions to this policy may be made for unforeseen emergencies, but must be discussed on a per case basis with the therapist. If you miss an appointment and do not contact the office about the reason, your next appointment is automatically cancelled. If you arrive more than 15 minutes late for your appointment, your session cannot be extended into the next client’s time; therefore, you will be charged as a missed appointment ($150). Insurance companies will not pay for sessions less than 45 minutes).

Fee Policy:

While the filing of insurance claims is a courtesy that is extended to you, all charges are ultimately your responsibility for the date of service. All co-payments, unmet deductible expenses, and services or charges not covered by insurance are due at the time of service. Any returned checks are subject to a $25 charge. Those who have out-of-network benefits must pay the full fee upfront and have the insurance company reimburse them. Should your account be referred for collections, you agree to pay 6% interest plus a $25 collection fee and reasonable attorney fees and/or court costs.

Fees for Services:

Fees for Services: I provide therapy for the fee of $225 per 50 minute session. I charge $225 per hour for reports, letters, and other documentation. Any services I provide beyond your therapy session, or what your insurance company has authorized, are charged to you directly at my hourly rate of $225 (charged in 15-minute increments), to include phone calls exceeding five minutes. Court appearances begin at $250 per hour. Fees for other services provided upon request.

Patient's Name:(Required)

Date(Required)

Consent for Care:(Required)

I give full consent for the completion of my evaluation and provision of treatment as necessary, by the above named provider, until otherwise notified. If I have any questions about the following information or about anything related to my case, I will discuss this with Dr. Truesdell Bierman.