Theresa Miller Registration

Teresa Miller, Ph.D.
5600Wyoming Blvd. NE
Suite 240
Albuquerque, NM 87109

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(Items in red are required fields.)

(MM-dd-yyyy)
Appointment Date:

Patient Information

First Name: Middle Initial: Last Name:

Address: City: State:

ZIP Code: Best number to contact you? Alternate Number:
E-Mail Address:

(MM-dd-yyyy)
Date of Birth:

Social Security Number:

Marital Status: Spouse Name: Payment Structure:

Emergency Contact: Phone: Relationship?

Patient Employer: Work Phone:

Primary Care Doctor: Phone Number:

Payment Information

Credit Card #: Expiration Date:

I hereby authorize Theresa Miller, Ph.D. to use the above credit card information to cover

any copays, coinsurance or self-pay amounts or amounts not covered by my insurance for payment.

Please type your full name to indicate your electronic signature:

Type Full Name:

Responsible Party Information

Check box if the patient is the responsible party.

Name: Address:

City: State: ZIP Code:

(MM-dd-yyyy)
Date of Birth:

Social Security Number:

Phone: Alternate Phone: Relationship:

INSURANCE INFORMATION

Have you contacted your insurance company about this appointment?

Primary Insurance Co. Phone:

Address: City: State:

ZIP Code: Name of Insured: Insured Id #:

Group #: SSN of Insured:
(MM-dd-yyyy)
Date of Birth:

Secondary Insurance Co. Phone:

Address: City: State:

ZIP Code: Name of Insured: Insured Id #:

Group #: SSN of Insured:

(MM-dd-yyyy)
Date of Birth:

Is this an Employee Assistance Program Visit (EAP) ? Auth #:

# of visits:

If you will be using your commercial insurance once your EAP visits have been exhausted, please fill out insurance information above.

How did you hear about us? Reason for seeking care?

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

I have been presented with a copy of Theresa Miller Ph.D.'s Notice of Privacy Policies, detailing how my information may be used and disclosed as permitted by federal and state law.

I understand the contents of the Notice, and I request the following restriction(s) concerning the use of my personal medical information:

Restrictions:

Please type your full name here to acknowledge receipt of Privacy notice:

                                                     CLIENT AGREEMENT
Please Initial
The patient or named responsible party is accountable for all service fees regardless of insurance coverage. Your provider is not responsible for ascertaining or guaranteeing the conditions for or amounts of coverage by your insurance company.

A full fee will be charged for failure to give at least twenty-four (24) hour notice for appointment cancelations. These fees are not payable by insurance.

A $10 re-billing fee or 1.5% may be charged on account balances over 90 days old and these delinquent accounts may be referred to a collection agency if reasonable effort is not made to pay them.

Payment at the rate of ________ per hour shall be made as follows.

Full payment is required at the time of service. [] Co-payment of ______ and/or amount of insurance deductible not met for this year to be paid at the time of service with the balance forthcoming from your insurance company.

Specify if other payment arrangements have been made:

                                                     STATEMENT OF RESPONSIBILITY:
The understanding certifies that he/she has read the foregoing and understands and acknowledges the terms of the agreement and is the patient or is duly authorized as the patient's agent to execute and accept its terms.

Please type your full name here to indicate your electronic signature:    Relationship to patient:

                                                     AUTHORIZATION TO RELEASE INFORMATION:
I hereby authorize (Provider) Theresa Miller, Ph.D. to release such information as may be necessary for the completion of my insurance claim forms and if applicable assessment, treatment planning, and treatment progress information to the managed care program of referral needed to establish authorization for care.

Please type your full name here to indicate your electronic signature:

                                                     PRIVACY STATEMENT:
This form contains information designed to inform you of your rights as a patient to the privacy of your medical record, how you can obtain access to your medical record and how we are committed to protecting client health information.

1.  You have the right to review and obtain copies of your medical information by signing a Release of Information Form which will become a permanent part of your medical record.
2.  You have the right to request and amendment or change to your medical record. The change or amendment will become a permanent part of your medical record in addition to the original information. At no time can we delete or alter client records.
3.  You have the right to a report that discloses individuals or organizations that have received information or a legal guardian. The only exceptions to this signed consent would be as listed on the Patient's Rights form:
   a.  If you threaten grave bodily harm to yourself or to another person, the necessary individuals, the intended victim and/or agencies will be informed to prevent harm.
   b.  If child neglect, physical abuse or sexual abuse is suspected, Children's Youth and Families Department will be notified.
   c.  If a court of law issues a legitmate subpoena.

4.  You hve the right to restrict the disclosure of information from your medical record. Understanding that if the disclosure is necessary for payment of services the request may not be agreed to.
5.  You have the right to request specific communication methods for receiving information regarding your health information. For example, you may request that we only contact you at work or at home, or that we only contact you by mail.

I have read and understand these rights as a client.
Please type your full name here to indicate your electronic signature:
                                                                                                                  Parent/Guardian (if client is under 14)

                                                     The rights of Clients and Informed Consent:
This form contains information designed to help your rights as a client and to make informed choices with regard to the therapeutic process. As a therapist, I value and encourage my clients to become active participants in the therapeutic relationship from beginning to the end. Therefore, the following information is provided for your education and welfare.

Client Rights:
   1.  To know the goals of the therapeutic program.
   2.  To know what services will be provided.
   3.  To know what behavior is expected to the client.
   4.  To know the benefits and risks of the therapeutic program.
   5.  To know alternatives to the therapeutic program.
   6.  To know the qualifications of the providers of services.
   7.  To know the financial agreements.
   8.  To know the estimated duration of therapy.
   9.  To know the rights to access your files.
   10.  To know about your rights pertaining to diagnostic labeling.
   11.  To know that your case may be discussed with consultants.
   12.  To know the right of confidentiality. Information is held in the strictest confidence and will not be revealed without your written permission. However, legal exceptions to confidentiality exist to protect yourself and others. The exceptions include:
        a. If you threaten grace bodily harm to yourself or to another person, I am required to inform necessary individuals, the intended victim and agencies to prevent harm.
        b. If child neglect, physical abuse or sexual abuse is suspected, I am required to notify the Children's Youth and Families Department.
        c. If a court of law issues a legitimate subpoena.

I have read my client rights and have had any questions clearly explained to me. I understand my rights as a client and consent to treatment. I understand that mental health counseling is an inexact science and there are no guarantees that a successful outcome will result.

Please type your full name here to indicate your electronic signature: