Welcome to Balanced Mind Behaviral Healthcare Our Mission at Balanced Mind Behaviral Healthcare is to provide quality compressive
behavioral mental health services that promote health, stability, and quality of life.
Our Vision is to be leaders of excellent personalized care, quality services, and accessible.
Our Goals are to provide easy access to your behavioral health needs.
Also, we collaborate with your health care providers to increase quality of life and healthy
living. Provide friendly, compassionate, and efficient care.
Balanced Mind Behaviral Healthcare is a place of hope, centered on health care that is personal
and compassionate. Our clinicalteam is caring, compassionate, and welltrained in
biologicalandpsycho-socialaspects that contribute tobehavioral,mental, andpsychotic
disorders.
For us to provide you effective care, please complete the attached evaluation forms.
We are looking forward to helping you achieve the optimal behavioral health needs.Thank you for allowing us to serve you!
Patient Demographic & Insurance Verification
Date:
Contact Number
First Name
Last Name
DOB
Current Age
Gender
Select Gender Male Female Others
Full Address
Email Address
Patient Status
Select Patient Status Student Single Married
Race
Select Race Asian/Vietnamese Black White Other
Ethnicity
Select Ethnicity Hispanic Not Hispanic Decline
Preferred Language
Select Preferred Language English Spanish Other
Primary Parent
Pharmacy name
Pharmacy phone
Pharmacy Address
Health Insurance Information
Name of Primary Insurance
Patient ID#
Group #
Insurance Phone Number
Authorization for Use & Disclosure Release of Protected Health Information Autorización para el Uso y Revelación (lanzamiento o de una solicitud) de
Información de salud protegida
Patient/Paciente
Date of Birth/Fecha de nacimiento
Doctor/Facility or Family Member
Full Address
Phone Number
Fax
Balanced Mind Behavioral Healthcare Inc This request/
authorization applies to Healthcare information relating to treatment and conditions.
The Information to be released includes/Please check specific information needed
(Por favor, compruebe la información específica necesaria)
This Release of Information demonstrates compliance with the Health Insurance Portability and Accountability Act
(HIPAA); and all federal regulations and interpretive guidelines there under. If the requestor or receiver is not
health care or plan provider, the released information may no longer be protected by Federal Privacy Regulation. I
understand that my records are confidential and cannot be disclosed without my written authorization, except when
otherwise permitted by law. I understand that the specified information to be released may include, but is not
limited to history, diagnoses, and or treatment of drug or alcohol abuse, mental illness, or communicable disease
including HIV and AIDS. I agree that a facsimile or photocopy of this authorization is as valid as the original. I
understand this authorization is voluntary, and that I may revoke this authorization in writing at any time
except to the extent that actions have been taken in reliance upon the authorization.
**Esta Divulgación de Información demuestra el cumplimiento con la Ley de Portabilidad y Responsabilidad del
Seguro Médico(HIPAA); Ytodas las regulaciones federales y las pautas deinterpretación allí debajo. Si el solicitante
o el receptor no es un proveedor de atención médica o plan, la información liberada puede no estar protegida por
el Reglamento Federal de Privacidad. Entiendo que mis registros son confidenciales y no pueden revelarse sin mi
autorización por escrito, excepto cuando la ley lo permita. Entiendo que la información especificada para ser
liberada puede incluir, pero no está limitada a: historia, diagnósticos y / o tratamiento de abuso de drogas o
alcohol, enfermedades mentales o enfermedades contagiosas, incluyendo el VIH y el SIDA. Estoy de acuerdo en
que un facsímil o fotocopia de esta autorización es tan válido como el original. Entiendo que esta autorización es
voluntaria, que yo revocar esta autorización por escrito en cualquier momento excepto en la medida en que se
CONSENT FOR TREATMENT FOR MENTAL/BEHAVIORAL SERVICES
Patient Last name, First Name
Date of Birth
I____(patient/ guardian name )__
hereby give my authorization and
consent for the above name to receive treatment for mental and behavioral services at Balanced Mind Behavioral Healthcare Inc
by a Board Certified Family Psychiatric Mental Health
Practitioners. Treatment consists of psychiatric examinations, diagnosis, and medication
management. I understand that complete and accurate information is needed to help provide the
best treatment plan and care. Moreover, during my care as a patient, I understand that the
purpose of treatments and procedures will be explained to me and that while the course of
medication management is designed to be helpful at times undesirable side effects may occur and
it is my responsibility to communicate these occurrences to my provider. I understand that I may
end treatment at any time. I understand that my mental health provider may want to discuss this
with me, but that I reserve the right to stop treatment. I understand that all information regarding
diagnosis and/or treatment is confidential and will not be released to any other agency or
individual without my knowledge and written consent, except when required by law.
Patient Name:
(Patient/Guardian Signature) Guardián
(Date)
Member Acknowledgement of Insurance Benefits
FINANCIAL AGREEMENT AND INSURANCE BENEFIT I hereby assign all medical benefits, to which I am entitled, including Medicare, Medicaid,
private insurance and any other health plans to Balanced Mind Behavioral Healthcare. This
assignment will remain in effect until revoked by myself in writing. A photocopy of charges
whether or not paid by said insurance. I hereby authorize said assignee to release all information
necessary to secure this payment. I understand that failure to notify Balanced Mind Behavioral
Healthcare of any changes or insurance coverage will result in the financial obligation to rest
fully on me regardless of any contract between the insurance company and Balanced Mind Behavioral
Healthcare clinic.
(Patient/GuardianSignature) Guardian
Date
PATIENT NAME
DATE OF BIRTH IN
FINANCIAL POLICY PATIENT CONSENT FORM Balanced Mind Behavioral Healthcare Inc
. RECOGNIZES THE NEED FOR A CLEAR
UNDERSTANDING BETWEEN PATIENT AND MEDICAL PROVIDER REGARDING PROTECTED
HEALTH INFORMATION AND FINANCIAL ARRANGEMENTS FOR HEALTHCARE. THE
FOLLOWING INFORMATION IS PROVIDED TO AVOID ANY MISUNDERSTANDING CONCERNING
PROTECTED HEALTH INFORMATION AND PAYMENT FOR PROFESSIONAL SERVICES.
I. PAYMENT: PAYMENT IS EXPECTED AT THE TIME OF SERVICE.
If your deductible has not been met, or a percentage is your responsibility, we expect payment when
services are rendered. Even though insurance will be filed, you are responsible for any balance after
insurance processes your claim. All charges for treatment become due and payable sixty (60) days after the
date of service. These periods allow sufficient time to process insurance and make payment in full of any
remaining balance. There will be a $25.00 charge for returned checks. If not paid within sixty (60) days,
Balanced Mind Behavioral Healthcare Inc
will begin various collection activities including, but not
limited to submitting the past due account to a collection agency.
II. SELF PAYMENT (PRIVATE, CASH PAYMENT):
If you have no insurance coverage, we ask that you coordinate your care with our business office prior to
your evaluation, follow-up, and treatment. We require an advance payment for professional services.
III. MANAGED CARE: ALL MANAGED CARE (MH, PPM, etc.) CO PAYMENTS ARE DUE AT
THE TIME OF SERVICE. By signing below, the patient acknowledges that it is the patient responsibility to
be aware of what services are covered and agrees to pay for any services deemed to be non-covered or not
authorized by the plan.
IV. MEDICARE: Balanced Mind Behavioral Healthcare Inc
is a participating provider with the
Medicare Program and accepts as payment, the Medicare allowable, patient deductible and/or 20%
co-insurance. If you have supplemental insurance (Medigap) to cover the portion of the charges that
Medicare does not pay, please provide us with a copy of your insurance card. Medicare or secondary
carriers do not cover some procedures and supplies. Please make certain you understand which aspects of
your treatment are covered before proceeding. In this rare case you may be asked to sign a waiver form,
which states that you understand that you will be responsible for these charges.
V. CHILDREN OF DIVORCED PARENTS: Responsibility for payment for treatment of minor
children, whose parents are divorced, rests with the parent who seeks the treatment. Any court-ordered
responsibility judgment must be determined between the individuals involved, without the inclusion of
Balanced Mind Behavioral Healthcare Inc
.
VI. SECONDARY INSURANCE: The Texas Department of Insurance requires the patient to provide
secondary insurance coverage to the provider if applicable. You agree to provide such information as
outlined below. You agree to notify the provider in the future immediately of any additions, changes or
deletions in primary or secondary coverage.
It is our hope that the above policies will allow us to provide the highest quality of care to
our patients. If you have any questions or need clarification regarding these policies
please call us at + 1 (817)677-0750.
OFFICE POLICIES & PROCEDURES OUR DISCLAIMER BY LAW WE COLLECT COPAY, CO-INSURANCE OR DEDUCTIBLE BEFORE WE CAN PROVIDE SERVICE. IT IS CONSIDERED INSURANCE FRAUD IF WE DON'T COLLECT
AND BILL YOUR INSURANCE. THANK YOU IN ADVANCE !
I AM RESPONSIBLE FOR MY OR MY CHILD’S COPAYS, CO-INSURANCE OR DEDUCTIBLES FEES AT THE TIME SERVICE IS RENDER BEFORE SEEING THE DOCTOR. FOR STANDARD OFFICE VISITS, I UNDERSTAND THAT THERE WILL BE A CHARGE OF $35 for NO CALL NO SHOW APPOINTMENT THAT I DO NOT GIVE 48 HOUR ADVANCE NOTICE TO CANCEL OR RESCHEDULE . FOR THERAPY VISITS, I UNDERSTAND THAT THERE WILL BE A CHARGE OF $55 for NO CALL NO SHOW APPOINTMENT THAT I DO NOT GIVE 48 HOUR ADVANCE NOTICE TO CANCEL OR RESCHEDULE. FOR STANDARD OFFICE VISITS, I UNDERSTAND THAT THERE WILL BE A CHARGE OF $20 FOR LAST MINUTE CANCELLATIONS GIVENLESSTHAN 48 HOURS. IAM RESPONSIBLEFOR CALLING THE CLINIC OR SENDING A TEXT MESSAGE TO TIMELY CANCEL MY OR MY CHILD’S APPOINTMENT. FOR THERAPY VISITS ,I UNDERSTAND THAT THERE WILL BE A CHARGE OF $40 FOR LAST MINUTE CANCELLATIONS GIVEN LESS THAN 48 HOURS. I AM RESPONSIBLE FOR CALLING THE CLINIC OR SENDING A TEXT MESSAGE TO TIMELY CANCEL MY OR MY CHILD’S APPOINTMENT. I UNDERSTAND THAT AN APPOINTMENT THAT IS SCHEDULED FROM 330PM UNTIL CLOSING IS GUARANTEED APPOINTMENTS. IF AN APPOINTMENT IS SET AND NOT KEPT,THEN YOU WILL CHARGED THEAPPROPRIATE NO-SHOW CANCELLATION FEE DESCRIBED ABOVE. IF YOU OR YOUR CHILD HAS FIVE OR MORE NO-SHOW APPOINTMENTS WITHIN ONE YEAR YOU WILL BE, AT THE CLINIC’S DISCRETION, DISCHARGED/DISMISSED FROM THEPRACTICE. I UNDERSTAND THAT THERE WILL BE A $10 FEE TO REPLACE EXPIRED PRESCRIPTION. WE CANNOT BILL YOUR INSURANCE COMPANY FOR THIS AMOUNT AS IT WILL BE SOLELY YOUR RESPONSIBLE TO PAY IN FULL. I UNDERSTAND THAT IT IS THE CLINIC’S POLICY AND DISCRETION TO REQUEST A POLICE REPORT TO REPLACE LOST OR STOLEN PRESCRIPTION. ALL OUTSTANDING PAYMENTS (AMOUNT DUE, NS/LC FEES OR FINANCIAL RESPONSIBILITY) MUST BE PAID. PAYMENT ARRANGEMENTS MUST BE MADE BEFORE SEEING DOCTOR. I UNDERSTAND AND AGREE THAT I AM FINANCIALLY RESPONSIBLE FOR ALL APPOINTMENTS NOT KEPT. (YOUR INSURANCE DOES NOT COVER LAST MINUTE, NO SHOWS, OR PAPERWORK FEES YOU MAY INQUIRE) I UNDERSTAND THAT BY CANCELLING AND/OR RESCHEDULING MY APPOINTMENT I AM RESPONSIBLE FOR MAKING SURE I (PARENT/PATIENT) HAVE ENOUGH MEDICATION TIL THE DOCTOR CAN SEE ME. I UNDERSTAND THAT IT IS THE PATIENT’S RESPONSIBILITY TO INFORM THE OFFICE OF ANY CHANGES IN INSURANCE. IF IFAILTO NOTIFYTHE OFFICE, IWILLBE RESPONSIBLE AND CHARGED FOR ANYOUTSTANDING VISITS MY INSURANCE DOES NOT COVER. CELLULAR DEVICES, CAMERAS, CAMCORDERS OR ANY RECORDING /PHOTO DEVICES OR PROHIBITED. (TO REDUCE THE POTENTIAL RISK OF FEDERAL HIPPA VIOLATION RECORDING/PHOTO TAKING DEVICES ARE PROHIBITED) IF THE CLINIC HAS TO CALL IN OR SUBMIT AN E-RX DUE TO YOUR INABILITY TO KEEP YOUR ORIGINAL APPOINTMENT DUE TO NO-SHOW OR LAST-MINUTE CANCELLATIONS, YOU WILL BE CHARGED $10 PER PRESCRIPTION.
HERE ARE NO EXCEPTIONS TO THE ABOVE OFFICE POLICIES. I UNDERSTAND THE OFFICE POLICY MAY BE AMENDED OR MODIFIED FROM TIME TO TIME BY THE PRACTICE.
Signature (Patient/Guardian)
Date
DISCLOSURE OF FEE SCHEDULE Most fees are for office and/or hospital procedures. However, fees will also be incurred
when you request services in addition to your regular services.
***Our office is not contracted and we are not legally obligated to complete
additional paperwork requested by your employer or other entity.
Brief, non-comprehensive listing of such services:
Medical records copied/transferred - $30 and up
Medical FMLA paperwork - $75 and up
Return or NSF Checks - $25 ***Please note, one returned check warrants our
discretion to not accept any future checks for the patient or parent of patient***
We do not complete Disability/Workers’ Comp forms or letters
Missed or no-show scheduled appointments with no notification incurs a fee of
$30 for standard appointments and $75 for therapy visits.
Last minute cancellation of a scheduled appointment with less than 48hr
notification will incur a fee of $25. Last minute cancellations of therapy
appointments will incur a fee of $50. NO SHOW FEE $55.
Lost/Stolen/Expired Prescription to be replaced will incur a $10 fee.
Our office under no circumstance will fill out forms or letters for CHL (Concealed
handgun permit) or Handicap Stickers.
We are not contracted by any government, commercial or medical entity therefore we
may refuse to sign any form or letter you may bring in. This is solely the discretion of
the clinic.
The above fees are not covered through your insurance plan and are payable at the time of service
rendered.
Patient/Guardian Signature
Date
CONTROLLED SUBSTANCE POLICY Controlled Stimulants prescriptions EXPIRE 21 DAYS after the appointment date, please make an effort to fill them in the appropriate time frame. If you feel your child’s medication needs to be increased, please discuss this during your office visit, not over the phone as the practitioner will not increase meds via phone calls. If your medication is lost/stolen, we will not rewrite any prescription without A POLICE REPORT. We encourage you to turn in or fill all prescriptions when they are issued. If you or your child is using ILLICIT DRUGS OF ANY KIND we will no longer prescribe your medication. If you alter the original prescription in any way, we will no longer prescribe your medication. If we discover you are getting the same prescription drugs from multiple pharmacies and/or physicians, we will no longer prescribe your medication. We do not do medication refills (especially controlled substances). You are required to make and keep your appointments as recommended in order to obtain these medications. If you know you will have to miss an appointment due to illness or another obligation, it is your responsibility to call and reschedule in order to avoid a disruption in your medication. We reserve the right to stop prescribing your medication if we feel there is a legitimate reason to include but not limited to: suspicious behavior, reports of misuse of medication, reports of illegal drug use/alcohol via urine/toxic screen. We reserve the right to terminate our service with you, if we feel there is a legitimate reason to include: Verbal abuse to our providers/staff, Threatening of any kind to the providers/staff, etc.
The guidelines in this policy are non-negotiable.
Patient/Guardian Signature
Date
Evaluations for Litigation Purposes Dear Clients,
Please be advised that Balanced Mind Behavioral Healthcare does not provide evaluations
(diagnosing) for litigation purposes. Litigation purposes would include criminal cases, divorce,
personal injury and emotional distress types of cases, among others. If you are looking to get an
evaluation for a litigation purpose and or disability, we recommend that you get a physician and/or
psychologist who specializes in performing such legal evaluations and treatment.
The providers at Balanced Mind Behavioral Healthcare Inc
do not provide litigation evaluations; our
purpose is strictly to assist you.
I acknowledge that I have read and understand the above statement.
Patient/Guardian Signature
Date
Grievance Procedure We are committed to you and your mental health needs here at Texas Advance Behavioral
Health. If you have concerns, feedback, or complaints we would like to know. The process for
patient who has a complaint, or a question is to:
Begin by discussing the concern with our front office Patient Care staff. This will
often clear up any misunderstanding.
If your concern is not dealt with to your satisfaction, you may inform our Clinical
Manager at + 1 (817)677-0750 or by emailing at [email protected] .
If your concern still is not addressed to your satisfaction, you may speak directly to
your provider or email your provider so they may assist you.
Patient/Guardian Signature
Date
Telemedicine Informed Consent Telemedicine services involve the use of secure interactive videoconferencing equipment and
devices that enable health care providers to deliver health care services to patients when located at
different sites.
I understand that the same standard of care applies to a telemedicine visit as applies to an
in-person visit.
I understand that I will not be physically in the same room as my health care provider. I will
be notified of and my consent obtained for anyone other than my healthcare provider present
in the room.
I understand that there are potential risks to using technology, including service interruptions,
interception, and technical difficulties. I understand that I have the right to refuse to participate or decide to stop participating in a
telemedicine visit, and that my refusal will be documented in my medical record. I also
understand that my refusal will not affect my right to future care or treatment.
I understand that the laws that protect privacy and the confidentiality of health care
information apply to telemedicine services.
I understand that my health care information may be shared with other individuals for
scheduling and billing purposes.
I understand that this document will become a part of my medical record
Patient/Guardian Signature
Date
INITIAL INTAKE QUESTIONNAIRE
PATIENT’S NAME
Date of Birth
Todays Date
Who referred you to the clinic?
What brings you to the clinic? (CHIEF COMPLAINT)
Please list all medications
Where have you been hospitalized and when?
If Yes Then When ?
If Yes . Please list issue(s)
LMP
Other problems:
Name
Last seen
SOCIAL HISTORY:
Who does the patient currently lives with
When?
Employment / Where do you work
Education: Highest School Grade
Name of school
Reports
Reports
Reports
What you use and when you used last
DEVELOPMENTAL HISTORY (Child & Adolescents Only): Was the patient born premature? When did they walk and talk? Patients Birth Weight?
REVIEW OF SYSTEMS -Circle if you have had any of these symptoms in the last month:
