Common use of Right to Request Restrictions Clause in Contracts

Right to Request Restrictions. You have the right to request in writing a restriction or limitation on medical information use or disclose about you. ♥Right to request confidential communication. You have the right to request that communication with you about your medical matters in a certain way or at a certain location. ♥Right to a paper copy of this notice. I will provide you with a copy of this notice upon your request. Your signature and date below acknowledges that you have been provided with this document regarding policies and practices concerning your protected health information (PHI). Your signature below also gives general consent for use or disclosure of your protected health information (PHI) for treatment, payment, and health care operations purposes. Your signature also allows us to leave voicemail messages, text messages at the telephone numbers you provide regarding confirming/changing appointments, questions about insurance, etc. Print Patient Name Patient Signature Date If patient under age-18 or Unable to consent. PRINT parent[s]name/ Sole Legal Guardian If patient under age-18 or Unable to consent. SIGNATURE of parent[s]name/ Sole Legal Guardian Date If Joint Custody of MinorPRINT name of Other/Parent/Other Legal Guardian If Joint Custody of MinorSIGNATURE of Other/Parent/Other Legal Guardian Date BN Counseling, LLC • Tax ID: 00-0000000 • T|000-000-0000 • F|000-000-0000 • xxxxxxx@xxxxxxxxxxxx.xxx 000 Xxxxxxxx Xxxxxxxx, Xxxxx 000, Xxxxxxx Xxxx, XX 00000 • 00 X 00xx Xx, 0xx Xxxxx, Xxxxxxx, XX 00000 🖐R E G I S T R A T I O N F O R M 🖐 🎔Client Name: Date of Birth: Age: Partner/ Spouses’ Name: Partner/ Spouses’ Date of Birth: Age: Child’s Name: Xxxxx’s Date of Birth: Age: Child’s Name: Xxxxx’s Date of Birth: Age: Client Address: City: Zip: Home Phone: Cell Phone: Work phone: Email Address: Gender: M F Trans Other: Ethnicity: □AA □White □Latino □Asian □Others: Marital Status: S Domestic Partner M W D Social Security No.: Place of Employment Partner /Spouse Name: Place of Employment Psychiatrist Name & Tel Number: Primary care physician Name & Tel Number: Referred By: May we thank this person for the referral? Yes No Emergency Contact: [Name & Telephone no.] Insurance Information Insurance Company: Insurance ID #: Subscriber’s Name: Date of Birth: Social Security Number: Address (if different from above): Release of Information & Assignment of Benefits I authorize to provide necessary clinical information requested by insurance companies to pay BNCounseling directly. I understand that I am responsible for any CHARGES OR SERVICES NOT COVERED BY MY INSURANCE COMPANY, including co-pays and deductibles. NO Cancellation Payment Policy Payment is kindly due at the time of service. Our office has a NO CANCELLATION POLICY and charges $80 for missed/no-shows or if you are late, including missed rescheduled appointments. Scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours notice is required for re-scheduling or canceling an appointment. We will however offer a make-up session as a courtesy for paid missed sessions. It Does Not Replace already scheduled appointment. Your insurance will not pay for missed sessions; these charges will be entirely your responsibility. Our office charges a $35 fee for returned checks and a $3.00 fee on all credit card transactions. Our collaboration is purposeful and significant. It gives you the tools and understanding necessary to have a thriving and fulfilled life. It is the price whom one contributes towards one's evolving change….and we are both worth it. Please make all checks payable to BN COUNSELING, LLC 00 X 00xx Xx, 0xx Xxxxx, Xxxxxxx, XX 00000 Signature: Printed signature functions as agreement to terms & conditions. Date: LIST OF CURRENT MEDICATIONS: List all tablets, patches, drops, ointments, injections, etc. Include prescription, over-the-counter, herbal, vitamin, and diet supplement products. Also list any medicine you take only on occasion 🎔Patient Name: DOB: Medication Name Dose How do you take it? How often do you take it? Reason for taking Date Started/ Changed Healthcare Provider □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject Allergies (please describe reaction) Doctor’s Name Phone Number Type of Practitioner / Reason for Seeing Payment Authorization Form Credit Card – ACH { Our relationship with money and t i me ref lects how we value ourselves and others} Thank you for choosing us as your wellness provider. While your wellness is our priority, we still must charge for missed appointments. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have about your coverage. The following questions may serve as a guide in helping you obtain pertinent information regarding eligibility and benefits. Kindly take time to read each statement and initial that you acknowledge and agree. Thank you. Initial At BN Counseling we respectfully request for your credit card information to ‘hold’ your reserved appointment, similar to when reservation agents ask for a credit card to hold a hotel room or a table at a restaurant. This helps reduce no-shows, ensures the appointment is paid for cancellations & missed appointments MISSED APPOINTMENTS. We understand that on rare occasions, true emergencies may arise. Our policy is to charge $80.00 for each missed/no-show therapy session including missed rescheduled appointments that are not rescheduled 48-hours in advance. Insurance health plans do not pay for missed appointments; these charges will be entirely your responsibility. Patients have the option of providing a signed check, which we only deposit for no-shows. Our office charges a $35 fee for any check returned for any reason and a $3.00 fee on all credit card transactions. Payments with a Flexible Spending Card is exempted from the fee. Here’s How Recurring Payments Work: You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected. Please complete the information below I (full name) authorize BN Counseling, LLC to charge my credit card as payment indicated below for scheduled appointments for payment of my sessions/co-payment/co-insurance/deductible. These charges include full payments for missed appointment unless otherwise negotiated. Billing Address: City State Zip Phone#: Email: Credit Card: □Visa □Master □Amex □Discover □Other: Cardholder Name: Account Number: Exp. Date: CVV (AMEX 4 digit number front of card) SIGNATURE DATE I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify BN Counseling, LLC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that BN Counseling, LLC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $30 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or cr edit card company; so long as the transactions correspond to the terms indicated in this authorization form. NO CANCELLATION PAYMENT POL ICY Ins urance О Missed Appointment Fees {Our relationship with money and time reflects how we value ourselves and others} Thank you for choosing us as your wellness provider. While your wellness is our priority, we still must cover this often uncomfortable topic about payments & missed appointments. Kindly take time to read each statement and initial that you acknowledge and agree. Thank you. Initial MISSED APPOINTMENTS. Rescheduling is preferred over cancellation. Weekly standing appointments are what we call “your time” meaning that we will honor “your time” in expectation of rendering you professional & courteous service for your scheduled appointment. Scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours notice is required for re-scheduling an appointment. If you miss or do not show up at “your time,” please be aware that you will be charged a cancellation fee of $80.00 for each missed/no-show therapy session including missed rescheduled appointments. Insurance health plans do not pay for missed appointments; these charges will be entirely your responsibility. We understand that on rare occasions, true emergencies may arise. We will do our absolute best to assist with rescheduling paid missed sessions due to true emergencies. Rescheduling appointments are highly dependent on availability that mutually converges for the client and counselor. We will however offer only 2 make-up opportunities as a courtesy for paid missed sessions. Rescheduled sessions DO NOT replace already scheduled weekly appointments.

Right to Request Restrictions. You have the right to request in writing a restriction or limitation on medical information use or disclose about you. ♥Right Right to request confidential communication. You have the right to request that communication with you about your medical matters in a certain way or at a certain location. ♥Right Right to a paper copy of this notice. I will provide you with a copy of this notice upon your request. Your signature and date below acknowledges that you have been provided with this document regarding policies and practices concerning your protected health information (PHI). Your signature below also gives general consent for use or disclosure of your protected health information (PHI) for treatment, payment, and health care operations purposes. Your signature also allows us to leave voicemail messages, text messages at the telephone numbers you provide regarding confirming/changing appointments, questions about insurance, etc. Print Patient Name Patient Signature Date If patient under age-18 or Unable to consent. PRINT parent[s]name/ Sole Legal Guardian If patient under age-18 or Unable to consent. SIGNATURE of parent[s]name/ Sole Legal Guardian Date If Joint Custody of MinorPRINT name of Other/Parent/Other Legal Guardian If Joint Custody of MinorSIGNATURE of Other/Parent/Other Legal Guardian Date BN Counseling, LLC • Tax ID: 00-0000000 • T|000-000-0000 • F|000-000-0000 • xxxxxxx@xxxxxxxxxxxx.xxx 000 Xxxxxxxx Xxxxxxxx, Xxxxx 000, Xxxxxxx Xxxx, XX 00000 • 00 X 00xx Xx, 0xx Xxxxx, Xxxxxxx, XX 00000 � �R E G I S T R A T I O N F O R M 🖐 🎔Clie Client nt Name: Date of Birth: Age: Partner/ Spouses’ Name: Partner/ Spouses’ Date of Birth: Age: Child’s Name: Xxxxx’s Date of Birth: Age: Child’s Name: Xxxxx’s Date of Birth: Age: Client Address: City: Zip: Home Phone: Cell Phone: Work phone: Email Address: Gender: M F Trans Other: Ethnicity: □AA □White □Latino □Asian □Others: Marital Status: S Domestic Partner M W D Social Security No.: Place of Employment Partner /Spouse Name: Place of Employment Psychiatrist Name & Tel Number: Primary care physician Name & Tel Number: Referred By: May we thank this person for the referral? Yes No Emergency Contact: [Name & Telephone no.] Insurance Information Insurance Company: Insurance ID #: Subscriber’s Name: Date of Birth: Social Security Number: Address (if different from above): Release of Information & Assignment of Benefits I authorize to provide necessary clinical information requested by insurance companies to pay BNCounseling directly. I understand that I am responsible for any CHARGES OR SERVICES NOT COVERED BY MY INSURANCE COMPANY, including co-pays and deductibles. NO Cancellation Payment PoliCANCELLATION PAYMENT POLICY cy Payment is kindly due at the time of service. Our office has a NO CANCELLATION POLICY and charges $80 for missed/no-shows or if you are late, including missed rescheduled appointments. Scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours notice is required for re-scheduling or canceling an appointment. We will however offer a make-up session as a courtesy for paid missed sessions. It Does Not Replace already scheduled appointment. Your insurance will not pay for missed sessions; these charges will be entirely your responsibility. Our office charges a $35 fee for returned checks and a $3.00 fee on all credit card transactions. Our collaboration is purposeful and significant. It gives you the tools and understanding necessary to have a thriving and fulfilled life. It is the price whom one contributes towards one's evolving change….and we are both worth iSignature: Printed signature functions as agreement to terms & conditions. Date: t. Please make all checks payable to BN COUNSELING, LLC 00 X 00xx Xx, 0xx Xxxxx, Xxxxxxx, XX 00000 Signature: Printed signature functions as agreement to terms & conditions. Date: LIST OF CURRENT MEDICATIONS: List all tablets, patches, drops, ointments, injections, etc. Include prescription, over-the-counter, herbal, vitamin, and diet supplement products. Also list any medicine you take only on occasion 🎔PatiPatient ent Name: DOB: Medication Name Dose How do you take it? How often do you take it? Reason for taking Date Started/ Changed Healthcare Provider □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject Allergies (please describe reaction) Doctor’s Name Phone Number Type of Practitioner / Reason for Seeing Payment Authorization Form Credit CPAYMENT AUTHORIZATION FORM CREDIT CARD ard – ACH { Our relationship with money and t iime me ref lects how we value ourselves and others} Thank you for choosing us as your wellness provider. While your wellness is our priority, we still must charge for missed appointments. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have about your coverage. The following questions may serve as a guide in helping you obtain pertinent information regarding eligibility and benefits. Kindly take time to read each statement and initial that you acknowledge and agree. Thank you. Initial At BN Counseling we respectfully request for your credit card information to ‘hold’ your reserved appointment, similar to when reservation agents ask for a credit card to hold a hotel room or a table at a restaurant. This helps reduce no-shows, ensures the appointment is paid for cancellations & missed appointments MISSED APPOINTMENTS. We understand that on rare occasions, true emergencies may arise. Our policy is to charge $80.00 for each missed/no-show therapy session including missed rescheduled appointments that are not rescheduled 48-hours in advance. Insurance health plans do not pay for missed appointments; these charges will be entirely your responsibility. Patients have the option of providing a signed check, which we only deposit for no-shows. Our office charges a $35 fee for any check returned for any reason and a $3.00 fee on all credit card transactions. Payments with a Flexible Spending Card is exempted from the fee. Here’s How Recurring Payments Work: You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected. Please complete the information below I (full name) authorize BN Counseling, LLC to charge my credit card as payment indicated below for scheduled appointments for payment of my sessions/co-payment/co-insurance/deductible. These charges include full payments for missed appointment unless otherwise negotiated. Billing Address: City State Zip Phone#: Email: Credit Card: □Visa □Master □Amex □Discover □Other: Cardholder Name: Account Number: Exp. Date: CVV (AMEX 4 digit number front of card) SIGNATURE DATE I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify BN Counseling, LLC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that BN Counseling, LLC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $30 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or cr edit card company; so long as the transactions correspond to the terms indicated in this authorization form. NO CANCELLATION PAYMENT POL ICY Ins urance О Missed Appointment Fees {Our relationship with money and time reflects how we value ourselves and others} Thank you for choosing us as your wellness provider. While your wellness is our priority, we still must cover this often uncomfortable topic about payments & missed appointments. Kindly take time to read each statement and initial that you acknowledge and agree. Thank you. Initial MISSED APPOINTMENTS. Rescheduling is preferred over cancellation. Weekly standing appointments are what we call “your time” meaning that we will honor “your time” in expectation of rendering you professional & courteous service for your scheduled appointment. Scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours notice is required for re-scheduling an appointment. If you miss or do not show up at “your time,” please be aware that you will be charged a cancellation fee of $80.00 for each missed/no-show therapy session including missed rescheduled appointments. Insurance health plans do not pay for missed appointments; these charges will be entirely your responsibility. We understand that on rare occasions, true emergencies may arise. We will do our absolute best to assist with rescheduling paid missed sessions due to true emergencies. Rescheduling appointments are highly dependent on availability that mutually converges for the client and counselor. We will however offer only 2 make-up opportunities as a courtesy for paid missed sessions. Rescheduled sessions DO NOT replace already scheduled weekly appointments.

Right to Request Restrictions. You have the right to request in writing a restriction or limitation on medical information use or disclose about you. ♥Right Right to request confidential communication. You have the right to request that communication with you about your medical matters in a certain way or at a certain location. ♥Right Right to a paper copy of this notice. I will provide you with a copy of this notice upon your request. Your signature and date below acknowledges that you have been provided with this document regarding policies and practices concerning your protected health information (PHI). Your signature below also gives general consent for use or disclosure of your protected health information (PHI) for treatment, payment, and health care operations purposes. Your signature also allows us to leave voicemail messages, text messages at the telephone numbers you provide regarding confirming/changing appointments, questions about insurance, etc. Print Patient Name Patient Signature Date If patient under age-18 or Unable to consent. PRINT parent[s]name/ Sole Legal Guardian If patient under age-18 or Unable to consent. SIGNATURE of parent[s]name/ Sole Legal Guardian Date If Joint Custody of MinorPRINT name of Other/Parent/Other Legal Guardian If Joint Custody of MinorSIGNATURE of Other/Parent/Other Legal Guardian Date BN Counseling, LLC • Tax ID: 00-0000000 • T|000-000-0000 • F|000-000-0000 • xxxxxxx@xxxxxxxxxxxx.xxx 000 Xxxxxxxx Xxxxxxxx, Xxxxx 000, Xxxxxxx Xxxx, XX 00000 • 00 X 00xx Xx, 0xx Xxxxx, Xxxxxxx, XX 00000 � �R E G I S T R A T I O N F O R M 🖐 🎔Clie Client nt Name: Date of Birth: Age: Partner/ Spouses’ Name: Partner/ Spouses’ Date of Birth: Age: Child’s Name: Xxxxx’s Date of Birth: Age: Child’s Name: Xxxxx’s Date of Birth: Age: Client Address: City: Zip: Home Phone: Cell Phone: Work phone: Email Address: Gender: M F Trans Other: Ethnicity: □AA □White □Latino □Asian □Others: Marital Status: S Domestic Partner M W D Social Security No.: Place of Employment Partner /Spouse Name: Place of Employment Psychiatrist Name & Tel Number: Primary care physician Name & Tel Number: Referred By: May we thank this person for the referral? Yes No Emergency Contact: [Name & Telephone no.] Insurance Information Insurance Company: Insurance ID #: Subscriber’s Name: Date of Birth: Social Security Number: Address (if different from above): Release of Information & Assignment of Benefits I authorize to provide necessary clinical information requested by insurance companies to pay BNCounseling directly. I understand that I am responsible for any CHARGES OR SERVICES NOT COVERED BY MY INSURANCE COMPANY, including co-pays and deductibles. NO Cancellation Payment PoliCANCELLATION PAYMENT POLICY cy Payment is kindly due at the time of service. Our office has a NO CANCELLATION POLICY and charges $80 for missed/no-shows or if you are late, including missed rescheduled appointments. Scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours notice is required for re-scheduling or canceling an appointment. We will however offer a make-up session as a courtesy for paid missed sessions. It Does Not Replace already scheduled appointment. Your insurance will not pay for missed sessions; these charges will be entirely your responsibility. Our office charges a $35 fee for returned checks and a $3.00 fee on all credit card transactions. Our collaboration is purposeful and significant. It gives you the tools and understanding necessary to have a thriving and fulfilled life. It is the price whom one contributes towards one's evolving change….and we are both worth iSignature: Printed signature functions as agreement to terms & conditions. Date: t. Please make all checks payable to BN COUNSELING, LLC 00 X 00xx Xx, 0xx Xxxxx, Xxxxxxx, XX 00000 Signature: Printed signature functions as agreement to terms & conditions. Date: LIST OF CURRENT MEDICATIONS: List all tablets, patches, drops, ointments, injections, etc. Include prescription, over-the-counter, herbal, vitamin, and diet supplement products. Also list any medicine you take only on occasion 🎔PatiPatient ent Name: DOB: Medication Name Dose How do you take it? How often do you take it? Reason for taking Date Started/ Changed Healthcare Provider □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject Allergies (please describe reaction) Doctor’s Name Phone Number Type of Practitioner / Reason for Seeing Payment Authorization Form Credit CPAYMENT AUTHORIZATION FORM CREDIT CARD ard – ACH { Our relationship with money and t i me ref lects how we value ourselves and others} Thank you for choosing us as your wellness provider. While your wellness is our priority, we still must charge for missed appointments. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have about your coverage. The following questions may serve as a guide in helping you obtain pertinent information regarding eligibility and benefits. Kindly take time to read each statement and initial that you acknowledge and agree. Thank you. Initial At BN Counseling we respectfully request for your credit card information to ‘hold’ your reserved appointment, similar to when reservation agents ask for a credit card to hold a hotel room or a table at a restaurant. This helps reduce no-shows, ensures the appointment is paid for cancellations & missed appointments MISSED APPOINTMENTS. We understand that on rare occasions, true emergencies may arise. Our policy is to charge $80.00 for each missed/no-show therapy session including missed rescheduled appointments that are not rescheduled 48-hours in advance. Insurance health plans do not pay for missed appointments; these charges will be entirely your responsibility. Patients have the option of providing a signed check, which we only deposit for no-shows. Our office charges a $35 fee for any check returned for any reason and a $3.00 fee on all credit card transactions. Payments with a Flexible Spending Card is exempted from the fee. Here’s How Recurring Payments Work: You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected. Please complete the information below I (full name) authorize BN Counseling, LLC to charge my credit card as payment indicated below for scheduled appointments for payment of my sessions/co-payment/co-insurance/deductible. These charges include full payments for missed appointment unless otherwise negotiated. Billing Address: City State Zip Phone#: Email: Credit Card: □Visa □Master □Amex □Discover □Other: Cardholder Name: Account Number: Exp. Date: CVV (AMEX 4 digit number front of card) SIGNATURE DATE I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify BN Counseling, LLC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that BN Counseling, LLC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $30 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or cr edit card company; so long as the transactions correspond to the terms indicated in this authorization form. NO CANCELLATION PAYMENT POL ICY Ins urance О Missed Appointment Fees {Our relationship with money and time reflects how we value ourselves and others} Thank you for choosing us as your wellness provider. While your wellness is our priority, we still must cover this often uncomfortable topic about payments & missed appointments. Kindly take time to read each statement and initial that you acknowledge and agree. Thank you. Initial MISSED APPOINTMENTS. Rescheduling is preferred over cancellation. Weekly standing appointments are what we call “your time” meaning that we will honor “your time” in expectation of rendering you professional & courteous service for your scheduled appointment. Scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours notice is required for re-scheduling an appointment. If you miss or do not show up at “your time,” please be aware that you will be charged a cancellation fee of $80.00 for each missed/no-show therapy session including missed rescheduled appointments. Insurance health plans do not pay for missed appointments; these charges will be entirely your responsibility. We understand that on rare occasions, true emergencies may arise. We will do our absolute best to assist with rescheduling paid missed sessions due to true emergencies. Rescheduling appointments are highly dependent on availability that mutually converges for the client and counselor. We will however offer only 2 make-up opportunities as a courtesy for paid missed sessions. Rescheduled sessions DO NOT replace already scheduled weekly appointments.

Right to Request Restrictions. You have the right to request in writing a restriction or limitation on medical information use or disclose about you. ♥Right to request confidential communication. You have the right to request that communication with you about your medical matters in a certain way or at a certain location. ♥Right to a paper copy of this notice. I will provide you with a copy of this notice upon your request. Your signature and date below acknowledges that you have been provided with this document regarding policies and practices concerning your protected health information (PHI). Your signature below also gives general consent for use or disclosure of your protected health information (PHI) for treatment, payment, and health care operations purposes. Your signature also allows us to leave voicemail messages, text messages at the telephone numbers you provide regarding confirming/changing appointments, questions about insurance, etc. Print Patient Name Patient Signature Date If patient under age-18 or Unable to consent. PRINT parent[s]name/ Sole Legal Guardian If patient under age-18 or Unable to consent. SIGNATURE of parent[s]name/ Sole Legal Guardian Date If Joint Custody of MinorPRINT name of Other/Parent/Other Legal Guardian If Joint Custody of MinorSIGNATURE of Other/Parent/Other Legal Guardian Date BN Counseling, LLC • Tax ID: 00-0000000 • T|000-000-0000 • F|000-000-0000 • xxxxxxx@xxxxxxxxxxxx.xxx 000 Xxxxxxxx Xxxxxxxx, Xxxxx 000, Xxxxxxx Xxxx, XX 00000 • 00 X 00xx Xx, 0xx Xxxxx, Xxxxxxx, XX 00000 🖐R E G I S T R A T I O N F O R M 🖐 🎔Client Name: Date of Birth: Age: Partner/ Spouses’ Name: Partner/ Spouses’ Date of Birth: Age: Child’s Name: Xxxxx’s Date of Birth: Age: Child’s Name: Xxxxx’s Date of Birth: Age: Client Address: City: Zip: Home Phone: Cell Phone: Work phone: Email Address: Gender: M F Trans Other: Ethnicity: □AA □White □Latino □Asian □Others: Marital Status: S Domestic Partner M W D Social Security No.: Place of Employment Partner /Spouse Name: Place of Employment Psychiatrist Name & Tel Number: Primary care physician Name & Tel Number: Referred By: May we thank this person for the referral? Yes No Emergency Contact: [Name & Telephone no.] Insurance Information Insurance Company: Insurance ID #: Subscriber’s Name: Date of Birth: Social Security Number: Address (if different from above): Release of Information & Assignment of Benefits I authorize to provide necessary clinical information requested by insurance companies to pay BNCounseling directly. I understand that I am responsible for any CHARGES OR SERVICES NOT COVERED BY MY INSURANCE COMPANY, including co-pays and deductibles. NO Cancellation Payment Policy Payment is kindly due at the time of service. Our office has a NO CANCELLATION POLICY and charges $80 for missed/no-shows or if you are late, including missed rescheduled appointments. Scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours notice is required for re-scheduling or canceling an appointment. We will however offer a make-up session as a courtesy for paid missed sessions. It Does Not Replace already scheduled appointment. Your insurance will not pay for missed sessions; these charges will be entirely your responsibility. Our office charges a $35 fee for returned checks and a $3.00 fee on all credit card transactions. Our collaboration is purposeful and significant. It gives you the tools and understanding necessary to have a thriving and fulfilled life. It is the price whom one contributes towards one's evolving change….and we are both worth it. Please make all checks payable to BN COUNSELING, LLC 00 X 00xx Xx, 0xx Xxxxx, Xxxxxxx, XX 00000 Signature: Printed signature functions as agreement to terms & conditions. Date: LIST OF CURRENT MEDICATIONS: List all tablets, patches, drops, ointments, injections, etc. Include prescription, over-the-counter, herbal, vitamin, and diet supplement products. Also list any medicine you take only on occasion 🎔Patient Name: DOB: Medication Name Dose How do you take it? How often do you take it? Reason for taking Date Started/ Changed Healthcare Provider □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject □Mouth □Inject Allergies (please describe reaction) Doctor’s Name Phone Number Type of Practitioner / Reason for Seeing Payment Authorization Form Credit Card – ACH { Our relationship with money and t iime me ref lects how we value ourselves and others} Thank you for choosing us as your wellness provider. While your wellness is our priority, we still must charge for missed appointments. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have about your coverage. The following questions may serve as a guide in helping you obtain pertinent information regarding eligibility and benefits. Kindly take time to read each statement and initial that you acknowledge and agree. Thank you. Initial At BN Counseling we respectfully request for your credit card information to ‘hold’ your reserved appointment, similar to when reservation agents ask for a credit card to hold a hotel room or a table at a restaurant. This helps reduce no-shows, ensures the appointment is paid for cancellations & missed appointments MISSED APPOINTMENTS. We understand that on rare occasions, true emergencies may arise. Our policy is to charge $80.00 for each missed/no-show therapy session including missed rescheduled appointments that are not rescheduled 48-hours in advance. Insurance health plans do not pay for missed appointments; these charges will be entirely your responsibility. Patients have the option of providing a signed check, which we only deposit for no-shows. Our office charges a $35 fee for any check returned for any reason and a $3.00 fee on all credit card transactions. Payments with a Flexible Spending Card is exempted from the fee. Here’s How Recurring Payments Work: You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit.” You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected. Please complete the information below I (full name) authorize BN Counseling, LLC to charge my credit card as payment indicated below for scheduled appointments for payment of my sessions/co-payment/co-insurance/deductible. These charges include full payments for missed appointment unless otherwise negotiated. Billing Address: City State Zip Phone#: Email: Credit Card: □Visa □Master □Amex □Discover □Other: Cardholder Name: Account Number: Exp. Date: CVV (AMEX 4 digit number front of card) SIGNATURE DATE I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify BN Counseling, LLC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that BN Counseling, LLC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $30 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or cr ecredit dit card company; so long as the transactions correspond to the terms indicated in this authorization form. NO CANCELLATION PAYMENT POL ICY Ins uraInsurance nce О Missed Appointment Fees {Our relationship with money and time reflects how we value ourselves and others} Thank you for choosing us as your wellness provider. While your wellness is our priority, we still must cover this often uncomfortable topic about payments & missed appointments. Kindly take time to read each statement and initial that you acknowledge and agree. Thank you. Initial MISSED APPOINTMENTS. Rescheduling is preferred over cancellation. Weekly standing appointments are what we call “your time” meaning that we will honor “your time” in expectation of rendering you professional & courteous service for your scheduled appointment. Scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours notice is required for re-scheduling an appointment. If you miss or do not show up at “your time,” please be aware that you will be charged a cancellation fee of $80.00 for each missed/no-show therapy session including missed rescheduled appointments. Insurance health plans do not pay for missed appointments; these charges will be entirely your responsibility. We understand that on rare occasions, true emergencies may arise. We will do our absolute best to assist with rescheduling paid missed sessions due to true emergencies. Rescheduling appointments are highly dependent on availability that mutually converges for the client and counselor. We will however offer only 2 make-up opportunities as a courtesy for paid missed sessions. Rescheduled sessions DO NOT replace already scheduled weekly appointments.