Knowledge of how to Prepare and Explain Initial Paperwork for a New Patient

  • To prepare initial paperwork, Collect the following paperwork from the black filing cabinet and place in the following order:

    • ​Registration Form (pink)

    • Release of Information – “For Release & Exchange of Protected Health Information”

    • Medication List

    • Fee Schedule/Special Circumstances

    • Services Agreement

    • Copy of Services Agreement Decline

    • Emergency Services Agreement

    • Contact Authorization/Out of Pocket Responsibility Agreement

    • Consent for Neurofeedback (if applicable)

    • Medical Review of Systems

    • Beck Youth (if applicable)

    • BAI (If applicable)

    • BDI (If Applicable)

  • ​According to the patient’s information collected on the New Patient Prescreening Form, fill in fields on each page with the information we have on file (Name, phone, address, insurance information, DOB, etc.)

  • Highlight patient SIGNATURE and DATE fields, as well as other required information from the patient in order to clearly specify what information we are asking the patient for. *see example chart for highlighted sections

  • Paperclip this packet (all paperwork listed above) and put in new chart

  • Also put either a Medical Initial Evaluation or a Psychological Initial Evaluation (depending on the diagnosis) for the clinician.

  • Explanation of initial paperwork:

    • ​Registration Form (pink) – this sheet is our general registration form that will list your patient and insurance information
    • Release of Information – “For Release & Exchange of Protected Health Information” – this sheet is for you to list the offices and individuals you authorize BMPC to release your patient information too
    • Medication List – this page provides a place for patients to document their current medications.

    • Fee Schedule/Special Circumstances – this page lists all potential services and their respective fees.
    • Services Agreement – this packet contains our services agreement
    • Copy of Services Agreement Decline – we offer patient a copy of our services agreement. This form needs to be signed and dated if the patient declines a copy of the services agreement.
    • Emergency Services Agreement – this sheet allows the patient to provide us with two emergency contacts in case of an emergency
    • Contact Authorization/Out of Pocket Responsibility Agreement – This sheet requests the patient’s permission to leave detailed messages over voicemail and through email, if desired. The second half of the page contains the patient’s agreement to pay any treatment costs not covered by insurance.
    • Consent for Neurofeedback (if applicable) - Please explain to the client to read the agreement, check all that apply on page 2, initial all statements on bottom of page 2, check all that apply on page 3, and sign and date on page 3.
    • Medical Review of Systems – this checklist provides the patient a space to document any and all symptoms that he or she may be experiencing
    • Beck Youth (if applicable) - Child needs to circle Never, Sometimes, Often, or Always next to each statement on all pages.
    • BAI (if applicable) – This questionnaire provides the patient the opportunity to document symptoms they’ve experienced within the past week, including the day of documentation. This questionnaire is related to symptoms indicating anxiety.
    • BDI (if applicable) – This questionnaire provides the patient the opportunity to document symptoms they’ve experienced within the past two weeks, including today. This questionnaire is related to symptoms indicating depression.