Assignment of Benefits: The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to Upper Valley Behavioral Health
LLC. I understand that I am financially responsible for any balance. I also authorize Upper Valley Behavioral Health LLC, its related companies, or insurance company to
release medical information required to process claims.
Notice of Privacy Practices: I have read or been offered a copy of Upper Valley Behavioral Health LLC's Notice of Privacy Practices (NPP), which explains how my medical
information will be used and disclosed. I authorize the release of my medical information necessary to provide care and bill on my behalf. I understand I am entitled to a
copy of the NPP.
Authorizations: I authorize medical treatment of the person named above and agree to pay all fees and charges for such treatment. I understand that medical treatment
may include a review of medical history and discussion of reason for visit. I authorize Upper Valley Behavioral Health LLC to disclose complete information concerning medical
finding and treatment of the undersigned, from the initial office visit until date of the conclusion of such treatment, to those individuals who, in Upper Valley Behavioral
Health LLC's determination, are required to receive such information for the purpose of medical treatment, medical quality assurance, peer review, and if applicable to process the insurance claim for services rendered at Upper Valley Behavioral Health LLC.
Consent for Communication: I understand Upper Valley Behavioral Health LLC will send appointment reminders and information on services via telephone, email and/or text
message based on the contact information I have provided. I understand that I will have the option to opt out of future text/email reminders.
Payment Policy: Payment is due at time of service, including copays and prior balance due. I understand I am responsible for all charges for services rendered on my
behalf, or on behalf of my dependents, less any amount paid by insurance to Upper Valley Behavioral Health LLC and its related companies.
Late or Missed Appointment Policy: We require a 48 business hours cancellation notice if you are not able to keep your appointment. Clients who no-show more than 2 times may be
asked to leave the practice. Families who perform a no-show for a double-visit will not be allowed to schedule double-visit appointments again.
WE DO NOT OFFER GRACE PERIODS. We recommend you arrive 10-15 minutes before your scheduled appointment time. If you arrive after your scheduled appointment time, you will be required to pay the no-show fee and you will be rescheduled for a different time/date.
Legal: This form applies to Upper Valley Behavioral Health LLC.
Patient Rights: I have read or been offered a copy of Upper Valley Behavioral Health LLC Patient Rights.
Patient Rights Document Received:
Medical History & Intake Form
Date of Birth (MM/DD/YYYY):
Are you pregnant?
Are you breastfeeding?
Select your sexual orientation:
I am looking for help with (select all that apply):
Select any mental health conditions you have been diagnosed with (select all that apply):
Have you tried any psychiatric medications in the past? If so, please list them.
Are you currently taking any prescription medications?
Do you have any allergies to any medications?
Have you had any surgeries in the past?
Have you been diagnosed with any medical conditions?
If you answer yes to any of the following questions, please explain below: