INITIAL VISIT INFORMATION SHEET
Date of Birth
If you are a student, permanent address:
Social Security #
Insurance information: (Please bring
your insurance card to be copied)
Claims mailing address
Name of subscriber:
(If not you, what is your relationship to subscriber?)
date of birth)
you obtain insurance authorization for this visit?
Whom may I thank for referring you to me?
authorize Sean F. Kelly, Ph.D. to furnish my insurance carrier with all information to process
my claim for services rendered. I understand that if my insurance should deny payment, I am responsible for the full charges.
If my plan requires preauthorization or referrals, I understand that it is my responsibility to request referrals from
my primary care provider in advance and to be aware of the terms of my plan benefits. I agree to be personally and fully responsible
for all charges. .I also acknowledge receipt of the required HIPPA notices and statements of patient rights and responsibilities
which are available on the web site and in the office. I can request a personal hard copy at any time.
I am aware that appointments represent a commitment of time to me by the provider and that insurance will not cover missed
appointments. I must provide 24 hours' notice of cancellation. If I give less than 24 hours' notice I
will be responsible for a charge of $100.00. If I miss an appointment without notice, I will be charged $125.00.
I have read and agree to the above information:
Sean F. Kelly, Ph.D.
Authorization to Release Confidential Information
You may find communication between your psychologist
and your primary care physician (PCP), other health care provider, or other professional to be important in order to ensure
comprehensive, coordinated quality health care. This form will allow me to share protected health information (PHI) with him
or her. This information will not be shared without your signed authorization and doing so is completely voluntary.
This PHI may include diagnosis, treatment plan and progress.
_____________________________________, d.o.b.___________________ authorize Sean F. Kelly, Ph.D., to release protected health
information related to my evaluation and treatment to:
You can end this authorization at any time by contacting me.
If you make a request to end this authorization, it will not include information
that has been used or disclosed based on your previous permission.
cannot be required to sign this form as a condition of treatment, payment, enrollment, or eligibility for benefits.
Information that is disclosed as a result of this authorization form may be re-disclosed
by the recipient and no longer protected by law.
You do not
have to agree to this request to use or disclose your information.
I, the undersigned, understand that I
may revoke this consent at any time except to the extent that action has been taken in reliance upon it and that in any case
this consent shall expire six (6) months from the date of signature, unless another date is specified. I have read and
understand the above information and give my authorization to release any applicable information to the above named individual