INFORMED CONSENT and NEW CLIENT FORMS
Below is a copy of the Consent to Treatment Form. I will ask you to sign this completed form at our first meeting. This Form gives me permission to be your therapist, establishes my fee and cancellation policy and serves as an acknowledgment that you were provided with a HIPAA Document. I will explain all of this information in more detail before asking you to sign the form.
If you're a new client, please complete the following forms and bring them to your first therapy session.
Also, please download and read the following HIPAA document. This document outlines my policies with regard to protecting your privacy, your rights as a patient, my cancellation policy and some of the limitations on confidentiuality while we work together.
COORDINATION OF CARE/RELEASE OF INFORMATION
To protect your privacy, I may not speak to anyone with regard to your work in therapy wothout your expressed and written permission. If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), or if you wish for me to be in contact with another individual or entity about your care (for example, a school counselor or administrator, an attorney or court, etc.) complete this form to authorize release of psychotherapy information:
OUT OF NETWORK Claim Forms
For your convenience, I have included claim forms from Major Insurance Providers that you can download, complete and print out to submit your claim for possible reimbursement. Please note that Joseph L. Nines takes no responsibility for the accuracy, revisions or determinations of claims by your insurance company.
- HighMark Blue Cross Blue Shield
- IBX PPO Out of Network
- Personal Choice
- United Health
Note: To download Adobe Acrobat Reader for free, click here.