Adult NP Ppwrork KCPG
Adult NP Ppwrork KCPG
Adult NP Ppwrork KCPG
(Please Print)
Email Address_________________________________________________________________________________________
Student Status: Full-time _____ Emergency Contact name and ph. #: ___________________________________________
Part-time_____
RESPONSIBLE PARTY
If other family members are seen in this office, please list: _______________________________________________________
*** AT THIS TIME A COPY OF YOUR CURRENT INSURANCE CARD AND PHOTO ID IS REQUESTED ***
ALTHOUGH WE TAKE A COPY OF YOUR INSURANCE CARD, WE DO REQUIRE THE FOLLOWING INFORMATION TO
BE COMPLETED.
I request that payment be made to Kansas City Psychiatric Group for any bills for service rendered to me by my doctor.
I understand that I am financially responsible to my doctor for any balance not covered by this authorization. I understand
that insurance filing is done as a courtesy for the patient and my doctor takes no responsibility for denial or delay of
payment.
_________________________________________________________________________________________________
Responsible Party’s Signature Printed Name of Signee Patient Name Date
By Typing and/or Signing above I attest that I understand and agree to the above statements
*We reserve the right to discharge any patient from this practice at any time for failure to comply with treatment
recommendations or office policy responsibilities. We will suggest referral options in this event.
_________________________________________________________________________________________________________
Responsible Party’s Signature Printed Name of Signee Patient Name Date
By Typing and/or Signing above I attest that I understand and agree to the above statements
I, Do________/Do Not ___________, authorize Kansas City Psychiatric Group to release information related to my evaluation and
treatment to:
Address:
_________________________________________________________________________________________________________
(Street) (City) (State) (Zip)
_________________________________________________________________________________________________________
Responsible Party’s Signature Printed Name of Signee Patient Name Date
If you would like to release medical information to another physician please request a separate release of information form
from the receptionist.
By Typing and/or Signing above I attest that I understand and agree to the above statements
_________________________________________________________________________________________________________
Responsible Party’s Signature Printed Name of Signee Patient Name Date
By Typing and/or Signing above I attest that I understand and agree to the above statements
Kansas City Psychiatric Group has adopted a policy, in order to comply with the HIPAA Privacy Regulation, requiring
physicians and staff to obtain authorization from the patient to leave detailed messages for that patient. This policy is to
protect the patient’s privacy. If there is not a signed consent on file, physicians and staff will only leave a name and
telephone number on an answering machine, voicemail, or with a live person answering the phone.
I have been given a copy of the Notice of Privacy Practices prior to signing this consent. Kansas City Psychiatric Group
reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be
obtained by forwarding a written request to Kansas City Psychiatric Group 8300 College Blvd., Suite 320, Overland Park,
Kansas 66210. It is also available online at www.kcpsych.com.
By completing the consent below, you are allowing Kansas City Psychiatric Group physicians and its staff to leave a
message on an answering machine, voicemail, or with a specified individual. You may also specify what information may
be left and with whom by noting the information at the bottom of this form.
I give my consent to Kansas City Psychiatric Group physicians and staff to leave a message regarding scheduling,
treatment, lab results or other information as necessary. (Check all that apply).
__________________________________________________________________________
Signature of Patient or Legal Guardian Date
By Typing and/or Signing above I attest that I understand and agree to the above statements
__________________________________________________________________________
Print Patient Name Print Name of Legal Guardian
Please read the following information carefully
Our office will do whatever we can to assist you. If you have any questions or problems, please do not hesitate
to contact our billing office.
All patients must complete the patient information form and sign this policy agreement in order to be seen in
this office.
We thank you for choosing KCPG and look forward to working with you. We strive to provide the very best
care and in order to do so we would like to take this opportunity to acquaint you with our office policies. Please
take a few moments to read over the following information. In addition, we suggest you review your health
insurance policy and familiarize yourself with the coverage and limitations that it provides.
APPOINTMENTS
We ask that you try to schedule your appointments as soon as possible--hopefully after each office visit--as routine
follow-up time slots are typically booked for several weeks into the future at any given point in time. If you are unable to
keep your appointment, please notify our office one working day (24 hours) in advance, to avoid being billed for the time.
A missed appointment will be billed at a rate determined by your physician and charged to your account. As
insurance does not pay for missed appointments, the patient/guarantor is responsible. Please note that two
consecutive missed appointments may result in being discharged from care. We will make an attempt to contact you
to confirm each appointment two working days ahead of time. This call is a courtesy, and our failure to reach you will
not relieve you of your responsibility for any missed appointment charges.
PRESCRIPTIONS
If you are on medication, please request any needed renewal prescriptions at the time of your appointment. In general,
you will be provided enough refills to last until your next expected appointment. If you do require refills between
appointments, please contact us at (913)338-0400, option 4 during regular phone hours 9AM to 4PM Monday
through Friday. Prescriptions for controlled substances cannot be called in and will require a written prescription.
Please notify our office of a need for a prescription three business days in advance. Failure to make follow-up
appointments as directed by the doctor, or missing a scheduled appointment, may result in a prescription fee.
Prescriptions may be picked up during business hours, Monday through Friday 9:00 am to 5:00 pm.
Fees due at the time of service include: co-pays, deductibles, non-covered services, or services to patients that are
not covered by insurance. For your convenience we accept, cash, check, MasterCard, Visa, American Express, and
Discover. If your check is returned from your financial institution you will be subject to a $30 service charge and
we will no longer be able to accept checks on your behalf.
• Alternately, you may choose to be seen as a self-pay patient. We will not be able to file your insurance for you
with this option; however, we can offer you a prompt pay discount when you pay in full on the date of
service. With this option you are welcome to file your insurance claim on your own for possible reimbursement.
FINANCIAL RESPONSIBILITY:
The person who brings a child for care is ultimately responsible for their bill. The physicians will not get involved in a
court decision or child support disputes.
YOU WILL RECEIVE A MONTHLY STATEMENT OF YOUR ACCOUNT AS LONG AS YOU HAVE A
BALANCE. In general, insurance companies should pay within thirty to sixty days after receipt of a claim. If your
insurance has not paid by sixty days after your visit, please check with your company as to the status of your claim. Your
insurance benefits are a contract between you and your insurance company. We cannot accept responsibility for
collecting your insurance or for negotiating a settlement on a disputed claim, but we will assist you whenever
possible. If you are a member of a health plan for which we are participating providers, we will honor any restrictions on
charges or fees, and these will be adjusted accordingly.
***WE RESERVE THE RIGHT TO SEND AN ACCOUNT TO COLLECTIONS IF NOT PAID IN FULL. IF
KCPG REFERS YOUR ACCOUNT OVER TO A COLLECTION AGENCY, YOU WILL BE RESPONSIBLE
FOR YOUR BALANCE PLUS THE COLLECTION AGENCY FEES***
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
Kansas City Psychiatric Group is committed to protecting your personal health information. If at any time you
have any questions or concerns about how your confidential information is being used you are encouraged to
notify the practice staff so that appropriate personnel can quickly address and resolve these concerns.
IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OR IF YOU NEED MORE INFORMATION,
PLEASE CONTACT OUR PRIVACY OFFICER:
• For Treatment. We may use or disclose your Protected Health Information to give you medical
treatment or services and to manage and coordinate your medical care. For example, your Protected
Health Information may be provided to a physician or other health care provider (e.g., a specialist or
laboratory) to whom you have been referred to ensure that the physician or other health care provider
has the necessary information to diagnose or treat you or provide you with a service.
• For Payment. We may use and disclose your Protected Health Information so that we can bill for the
treatment and services you receive from us and can collect payment from you, a health plan, or a third
party. This use and disclosure may include certain activities that your health insurance plan may
undertake before it approves or pays for the health care services we recommend for you, such as making
a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for
medical necessity, and undertaking utilization review activities. For example, we may need to give your
health plan information about your treatment in order for your health plan to agree to pay for that
treatment.
• For Health Care Operations. We may use and disclose Protected Health Information for our health
care operations. For example, we may use your Protected Health Information to internally review the
quality of the treatment and services you receive and to evaluate the performance of our team members
in caring for you. We also may disclose information to physicians, nurses, medical technicians, medical
students, and other authorized personnel for educational and learning purposes.
• Minors. We may disclose the Protected Health Information of minor children to their parents or
guardians unless such disclosure is otherwise prohibited by law.
• As Required by Law. We will disclose Protected Health Information about you when required to do so
by international, federal, state, or local law.
• To Avert a Serious Threat to Health or Safety. We may use and disclose Protected Health
Information when necessary to prevent a serious threat to your health or safety or to the health or safety
of others, but we will only disclose the information to someone who may be able to help prevent the
threat.
• Business Associates. We may disclose Protected Health Information to our business associates who
perform functions on our behalf or provide us with services if the Protected Health Information is
necessary for those functions or services. For example, we may use another company to do our billing,
or to provide transcription or consulting services for us. All of our business associates are obligated,
under contract with us, to protect the privacy and ensure the security of your Protected Health
Information.
• Organ and Tissue Donation. If you are an organ or tissue donor, we may use or disclose your Protected
Health Information to organizations that handle organ procurement or transplantation – such as an organ
donation bank – as necessary to facilitate organ or tissue donation and transplantation.
• Military and Veterans. If you are a member of the armed forces, we may disclose Protected Health
Information as required by military command authorities. We also may disclose Protected Health
Information to the appropriate foreign military authority if you are a member of a foreign military.
• Workers’ Compensation. We may use or disclose Protected Health Information for workers’
compensation or similar programs that provide benefits for work-related injuries or illness.
• Public Health Risks. We may disclose Protected Health Information for public health activities. This
includes disclosures to: (1) a person subject to the jurisdiction of the Food and Drug Administration
(“FDA”) for purposes related to the quality, safety or effectiveness of an FDA-regulated product or
activity; (2) prevent or control disease, injury or disability; (3) report births and deaths; (4) report child
abuse or neglect; (5) report reactions to medications or problems with products; (6) notify people of
recalls of products they may be using; and (7) a person who may have been exposed to a disease or may
be at risk for contracting or spreading a disease or condition.
• Abuse, Neglect, or Domestic Violence. We may disclose Protected Health Information to the
appropriate government authority if we believe a patient has been the victim of abuse, neglect, or
domestic violence and the patient agrees or we are required or authorized by law to make that disclosure.
• Health Oversight Activities. We may disclose Protected Health Information to a health oversight
agency for activities authorized by law. These oversight activities include, for example, audits,
investigations, inspections, licensure, and similar activities that are necessary for the government to
monitor the health care system, government programs, and compliance with civil rights laws.
• Data Breach Notification Purposes. We may use or disclose your Protected Health Information to
provide legally required notices of unauthorized access to or disclosure of your health information.
• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Protected Health
Information in response to a court or administrative order. We also may disclose Protected Health
Information in response to a subpoena, discovery request, or other legal process from someone else
involved in the dispute, but only if efforts have been made to tell you about the request or to get an order
protecting the information requested. We may also use or disclose your Protected Health Information to
defend ourselves in the event of a lawsuit.
• Law Enforcement. We may disclose Protected Health Information, so long as applicable legal
requirements are met, for law enforcement purposes.
• Military Activity and National Security. If you are involved with military, national security or
intelligence activities or if you are in law enforcement custody, we may disclose your Protected Health
Information to authorized officials so they may carry out their legal duties under the law.
• Coroners, Medical Examiners, and Funeral Directors. We may disclose Protected Health
Information to a coroner, medical examiner, or funeral director so that they can carry out their duties.
• Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement
official, we may disclose Protected Health Information to the correctional institution or law enforcement
official if the disclosure is necessary (1) for the institution to provide you with health care; (2) to protect
your health and safety or the health and safety of others; or (3) the safety and security of the correctional
institution.
Uses and Disclosures That Require Us to Give You an Opportunity to Object and Opt Out
• Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose
to a member of your family, a relative, a close friend or any other person you identify, your Protected
Health Information that directly relates to that person’s involvement in your health care. If you are
unable to agree or object to such a disclosure, we may disclose such information as necessary if we
determine that it is in your best interest based on our professional judgment.
• Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations that
seek your Protected Health Information to coordinate your care, or notify family and friends of your
location or condition in a disaster. We will provide you with an opportunity to agree or object to such a
disclosure whenever we practicably can do so.
The following uses and disclosures of your Protected Health Information will be made only with your written
authorization:
1. Most uses and disclosures of psychotherapy notes;
2. Uses and disclosures of Protected Health Information for marketing purposes; and
3. Disclosures that constitute a sale of your Protected Health Information.
Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to
us will be made only with your written authorization. If you do give us an authorization, you may revoke it at
any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected
Health Information under the authorization, but disclosure that we made in reliance on your authorization before
you revoked it will not be affected by the revocation.
You have the following rights, subject to certain limitations, regarding your Protected Health Information:
• Right to Inspect and Copy. You have the right to inspect and copy Protected Health Information that
may be used to make decisions about your care or payment for your care. We have up to 30 days to
make your Protected Health Information available to you and we may charge you a reasonable fee for
the costs of copying, mailing or other supplies associated with your request. We may not charge you a
fee if you need the information for a claim for benefits under the Social Security Act or any other state
or federal needs-based benefit program. We may deny your request in certain limited circumstances. If
we do deny your request, you have the right to have the denial reviewed by a licensed healthcare
professional chosen by KCPG who was not directly involved in the denial of your request, and we will
comply with the outcome of the review.
• Right to a Summary or Explanation. We can also provide you with a summary of your Protected
Health Information, rather than the entire record, or we can provide you with an explanation of the
Protected Health Information which has been provided to you, so long as you agrees to this alternative
form and pay the associated fees.
• Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is
maintained in an electronic format (known as an electronic medical record or an electronic health
record), you have the right to request that an electronic copy of your record be given to you or
transmitted to another individual or entity. We will make every effort to provide access to your
Protected Health Information in the form or format you request, if it is readily producible in such form
or format. If the Protected Health Information is not readily producible in the form or format you request
your record will be provided in either our standard electronic format or if you do not want this form or
format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor
associated with transmitting the electronic medical record.
• Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your
unsecured Protected Health Information.
• Right to Request Amendments. If you feel that the Protected Health Information we have is incorrect
or incomplete, you may ask us to amend the information. You have the right to request an amendment
for as long as the information is kept by or for us. A request for amendment must be made in writing to
the Privacy Officer at the address provided at the beginning of this Notice and it must tell us the reason
for your request. In certain cases, we may deny your request for an amendment. If we deny your request
for an amendment, you have the right to file a statement of disagreement with us and we may prepare a
rebuttal to your statement and will provide you with a copy of any such rebuttal.
• Right to an Accounting of Disclosures. You have the right to ask for an “accounting of disclosures,”
which is a list of the disclosures we made of your Protected Health Information. This right applies to
disclosures for purposes other than treatment, payment or healthcare operations as described in this
Notice. It excludes disclosures we may have made to you, for a resident directory, to family members or
friends involved in your care, or for notification purposes. The right to receive this information is subject
to certain exceptions, restrictions and limitations. Additionally, limitations are different for electronic
health records. The first accounting of disclosures you request within any 12-month period will be free.
For additional requests within the same period, we may charge you for the reasonable costs of providing
the accounting. We will tell what the costs are, and you may choose to withdraw or modify your request
before the costs are incurred.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the Protected
Health Information we use or disclose for treatment, payment, or health care operations. You also have
the right to request a limit on the Protected Health Information we disclose about you to someone who is
involved in your care or the payment for your care, like a family member or friend. To request a
restriction on who may have access to your Protected Health Information, you must submit a written
request to the Privacy Officer. Your request must state the specific restriction requested and to whom
you want the restriction to apply. We are not required to agree to your request, unless you are asking us
to restrict the use and disclosure of your Protected Health Information to a health plan for payment or
health care operation purposes and such information you wish to restrict pertains solely to a health care
item or service for which you have paid us “out-of-pocket” in full. If we do agree to the requested
restriction, we may not use or disclose your Protected Health Information in violation of that restriction
unless it is needed to provide emergency treatment.
• Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that we not
bill your health plan) in full for a specific item or service, you have the right to ask that your Protected
Health Information with respect to that item or service not be disclosed to a health plan for purposes of
payment or health care operations, and we will honor that request.
• Right to Request Confidential Communications. You have the right to request that we communicate
with you only in certain ways to preserve your privacy. For example, you may request that we contact
you by mail at a specific address or call you only at your work number. You must make any such
request in writing and you must specify how or where we are to contact you. We will accommodate all
reasonable requests. We will not ask you the reason for your request.
• Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice, even if you
have agreed to receive this Notice electronically. You may request a copy of this Notice at any time.
Complaints
You may file a complaint with us or with the Secretary of the United States Department of Health and Human
Services if you believe your privacy rights have been violated.
To file a complaint with us, contact our Privacy Officer at the address listed at the beginning of this Notice. All
complaints must be made in writing and should be submitted within 180 days of when you knew or should have
known of the suspected violation. There will be no retaliation against you for filing a complaint.
To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and Human
Services, 200 Independence Ave, S.W., Washington, D.C. 20201. Call (202) 619-0257 (or toll free (877) 696-
6775) or go to the website of the Office for Civil Rights, www.hhs.gov/ocr/hipaa/, for more information. There
will be no retaliation against you for filing a complaint.