Client Intake Forms

Client-intakeform-

Step 1 of 8

Client Information Form
Client Information Form

First Name*
Last Name*
Middle Initial
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number
Social Security Number
Date
Date Format: MM slash DD slash YYYY

Emergency Contact Name/Phone Number*
FOR MEDICAID RECIPIENTS ONLY
Name of Insurance Company
Member ID Number
Medicaid ID Number
PLEASE PROVIDE THE FOLLOWING INFORMATION ONLY IF YOU HAVE COMMERCIAL INSURANCE:
Name Policy Holder
DOB of Policy Holder
Date Format: MM slash DD slash YYYY

Relationship to Client
Place of Employment
Name of Insurance Company
Member ID
Group Number
Copay Amount
Annual Deductible Amount

Clients Rights
Clients Rights

Right to request how we contact you.
It is our normal practice to communicate with you at your home address and daytime phone number you gave us when you scheduled your appointment, about health matters, such as appointment reminders etc. Sometimes we may leave messages on your voicemail. You have the right to request that our office communicate with you in a different way.
Right to release your medical records.
You may consent in writing to release your recordsto others. You have the right to revoke this authorization, inwriting, at any time. However, a revocation is not valid to the extent that we acted in reliance on such authorization
Right to inspect and copy your medical and billing records.
You have the right to inspect and obtain a copy of your information contained in our medical records. To request access to your billing or health information, contact the office manager. Under limited circumstance we may deny your request to inspect and copy. If you as k for a copy of any information, we may charge a reasonable fee for the costs of copying, mailing and supplies.
Right to add information or amend your medical records.
If you feel that information contained in your medical record is incorrect or incomplet e, you may ask us to add information to amend the record. We will make a decision on your request with 60 days, or some cases within 90 days. Under certain circumstance, we may deny your request to add or amend information. If we deny your request, you have a right to file a statement that you disagree. Your statement and our response will be added to your record. To request an amendment, you must contact the office manager. We will require you to submit your request in writing and to provide an explanation concerning the reason for your request
Right to an accounting of disclosures.
You may request an accounting of any disclosures, if any, we have made related to your medical information, except for information we used for treatment, payment, or health care operational purposes or that we shared with you or your family, or information that you gave us specific consent to release. It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003, please submit your request in writing to the Privacy Officer. We will notify you of the cost involved in preparing this list.
Right to request restrictions on uses and disclosures of your health information.
You have the right to ask for restrictions on certain uses and disclosures of your health information. This requestmust be in writing and submitted to our office manager. However, we are not required to agree to such a request.
Right to complain.
If you believe your privacy rights have been violated, please contact us personally, and discuss your concerns. If you are not satisfied with the outcome, you may file a written complaint with the U.S. Department of Health and Human Services. An individ ual will not be retaliated against for filing such a complaint
*
I HAVE READ, UNDERSTOOD, AND AGREE TO ALL OF THE ABOVE INFO.

Consent to Release Information
Consent to Release Information

I consent for Kentucky Mental Health Care, LLC and those representing this group to share my (or my child’s) private health care information with the following individuals and/or entities. KMHC is permitted to send and receive information to and from the entities below if needed:
Representatives of Child’s School (School Name)*
Primary Care Physician Name*
Emergency Contact Name*
Other/ Self*
I understand that I have the right to revoke this authorization, in writing, at any time by sending notice to Kentucky Mental Health Care, LLC. I understand that a revocation is not valid to the extent that Kentucky Mental Health Care, LLC has acted in reliance on such authorization. This authorization does not expire until I submit a written request. A copy of this release shall have the same force and effect as the original.

NOTICE TO RECEIVING PROVIDEROR ORGANIZATION: You may not re-disclose any of this information unless the person who consented to this disclosure specifically consents to such re-disclosure. I understand that there is a potential for disclosure of this information by the recipient and, if that occurs, federal law may not protect the information.
Client Signature (Parent/Guardian must sign if client is a minor
Date*
Date Format: DD slash MM slash YYYY

Signature*
5115 S. 3rd Street | Louisville, KY 40214 | 502-233-3030 | KentuckyMentalHealth.com

HIPAA Notice of Privacy Practices
HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSEDAND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice describes our policies related to the use and disclosure of your healthcare information. Your health information may be used for the purposes of providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allows us to use and disclose your health information for these purposes.
TREATMENT We may need to use or disclose health information about you to provide, manage or coordinate your care or related services. Which could include consultants and potential referral sources.
PAYMENT PAYMENT Information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes. We may bill the person in your family who pays for your insurance.
HEALTHCARE OPERATIONS We may need to use information about you to review our treatment procedures and business activity. Information may be used for certification, compliance and licensing activities.
There are some instances where we may be required to use and disclose information without your consent. For example, but not limited to: Information you and/or your child or children report about physical or sexual abuse: then by Kentucky State Law, we are obligated to report this to the Department of Children and Family Services; If you provide information that informs us that you are in danger of harming yourself or others, we must report this also; Information may be used to remind you of /or to reschedule appointments or treatment alternatives; Information shared with law enforcement if a crime is committed on our premises or against our staff or as required by law such as a subpoena or court order; Clinical records, psychotherapy notes and other disclosures require a separate signed release of information.
You have a right to or will receive notification of a breach of any unsecured personal health information. You have a right to restrict any disclosure of personal health information where you have paid for services out-ofpocket and in full.
METHOD OF CONTACT BY OFFICE
We may send you appointment reminders by text message or phone call and leave a voice message. NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS: I have read and received a copy of the Notice of Privacy Practices and Client Rights document.
Client/Guardian Signature**
Date*
Date Format: MM slash DD slash YYYY

Informed Consent
INFORMED CONSENT
By signing this form, you agree to receive mental health services provided by Kentucky Mental Health Care, LLC, and its independent contractors. We know that starting counseling is a big decision and you may have many questions. We will do our best to answer any questions or concerns. This form explains information about KMHC policy, State and Federal Laws, and your rights about counseling. All KMHC employees and contractors have met the highest level of education, certification, and licensing requirements set forth by Kentucky state law. Counseling practices, philosophy and plan limitations and risks will be discussed with you today

TREATMENT PROCESS AND DOCUMENTATION
It is the mental health professional’s responsibility to keep accurate records including Evaluations, Treatment Plans, and Progress Notes. By signing this document, you are consenting to the Treatment Plan that your provider creates and agree to any goals, objectives, and therapy techniques that may be used in your therapy process

INSURANCE BILLING
If you plan to use insurance to pay for services, claims will be sent to the insurance company based on information used at the time of service. Sometimes, insurance information may change or may not be up to date. If for any reason, inaccurate information related to deductibles, co-pays, or number of available sessions, etc. is retrieved at the time of service, KMHC will bill the client for any additional costs associated with mental health services rendered. Additional services may not be provided until the client’s balance is current. If balances remain unpaid for 60 days, client information will be sent to a collection agency.

CONFIDENTIALITY AND EMERGENCY SITUATIONS:
Confidential information discussed in session is not discussed with anyone without your written permission except for:
1. Diagnosis and dates of service shared with your insurance company to process your claims
2. Information you tell KMHC about physical, sexual or elder abuse; then, by Kentucky State Law, I have to report this to the Kentucky Department of Children and Family Services
3. Where you sign a release of information to have specific information shared
4. If you tell KMHC you are in danger of harming yourself or others
5. Information shared with
6. When required by law.
If you need to contact me between counseling sessions, please call my office. E-mail, text messages and social networking sites are not confidential and I may not be able to respond. If an emergency situation would happen, you can call my office to have a counselor call you. If no call is received within 15 minutes or you can’t wait call 911.

CONFIDENTIALITY AND EMERGENCY SITUATIONS:
Confidential information discussed in session is not discussed with anyone without your written permission except for: 1. Diagnosis and dates of service shared with your insurance company to process your claims 2. Information you tell KMHC about physical, sexual or elder abuse; then, by Kentucky State Law, I have to report this to the Kentucky Department of Children and Family Services 3. Where you sign a release of information to have specific information shared 4. If you tell KMHC you are in danger of harming yourself or others 5. Information shared with 6. When required by law. If you need to contact me between counseling sessions, please call my office. E-mail, text messages and social networking sites are not confidential and I may not be able to respond. If an emergency situation would happen, you can call my office to have a counselor call you. If no call is received within 15 minutes or you can’t wait call 911.
Client/Guardian Signature**
Date*
Date Format: MM slash DD slash YYYY

Patient Attestation
Patient Attestation Form/Participation in the Development of the Plan of Care
I verify that I have participated in the development of the plan of care with my service provider, and that the plan of care is based upon my unique need and circumstances, as reported. I understand that an interdisciplinary team approach will be utilized for the achievement of this plan of care when warranted. In signing this attestation, I declare that my views and choices have been considered in the plan of care development. For children: As parent/guardian of the child specified above, I give permission for collateral services on behalf of my child.
I verify that I have participated in the development of the plan of care with my service provider, and that the plan of care is based upon my unique need and circumstances, as reported. I understand that an interdisciplinary team approach will be utilized for the achievement of this plan of care when warranted.
In signing this attestation, I declare that my views and choices have been considered in the plan of care development. For children: As parent/guardian of the child specified above, I give permission for collateral services on behalf of my child.

Date of initial plan of Care:*
Date Format: MM slash DD slash YYYY

(Signature of client/parent/Guardian)*
Today’s Date*
Date Format: MM slash DD slash YYYY

Telehealth Consent
I agree to participate in a telemedicine evaluation and/or ongoing treatment performed by an independently contracted provider who assumes sole responsibility and liability for treatment. By signing this agreement, I authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care. *Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small. I understand that I can withdraw my permission at any time and that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a telemedicine session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face consultation. I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a specialist in person. I understand that medical records of telemedicine services will be kept at Kentucky Mental Health Care. I understand that some or all of my medical information may be used for teaching or educational purposes. I agree to have my telemedicine medical records reviewed for the purposes of evaluation (data collection, analysis and presentation in verbal or written format at scientific meetings). I understand that any presentation will not identify me by name or other identifiable markers.
Client Name:*
Client Signature:*
Today’s Date*
Date Format: MM slash DD slash YYYY

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Client Intake Forms

Client-intakeform-

Step 1 of 8

WELCOME to the New Client Intake Forms Section:

Targeted Case Management

What to expect

Client Information Form

Client Information Form

FOR MEDICAID RECIPIENTS ONLY

PLEASE PROVIDE THE FOLLOWING INFORMATION ONLY IF YOU HAVE COMMERCIAL INSURANCE:

Clients Rights

Clients Rights

Right to request how we contact you.

Right to release your medical records.

Right to inspect and copy your medical and billing records.

Right to add information or amend your medical records.

Right to an accounting of disclosures.

Right to request restrictions on uses and disclosures of your health information.

Right to complain.

Consent to Release Information

Consent to Release Information

I consent for Kentucky Mental Health Care, LLC and those representing this group to share my (or my child’s) private health care information with the following individuals and/or entities. KMHC is permitted to send and receive information to and from the entities below if needed:

HIPAA Notice of Privacy Practices

HIPAA NOTICE OF PRIVACY PRACTICES

METHOD OF CONTACT BY OFFICE

Informed Consent

INFORMED CONSENT

TREATMENT PROCESS AND DOCUMENTATION

INSURANCE BILLING

CONFIDENTIALITY AND EMERGENCY SITUATIONS:

CONFIDENTIALITY AND EMERGENCY SITUATIONS:

Patient Attestation

Patient Attestation Form/Participation in the Development of the Plan of Care

Telehealth Consent

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