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Adolescents 12-17
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Visitation Guidelines
Request Medical Records
520-322-2888
Patient Self Screening
Patient Self Screening
Name
First
Last
Date
MM slash DD slash YYYY
Name of Person Completing Form
Relationship
Referral Source
Family/Friend
Internet
TV
Outpatient Facility
Medical or Psychiatric Provider
Other
Other (specify):
Have you had any previous hospitalizations
YES
NO
When:
Name of Hospital:
Reason for Admission:
What level of service are you seeking today
Inpatient treatment
Intensive Outpatient
Partial Hospitalization
Treatment Recommendations
Other
Areas of Concern (Please check any and all related symptoms and explain if possible):
Feelings of Wanting to Harm Self
Right now
Today
Past month
Past 6mos
Explain, if possible
Feelings of Wanting to Harm Others
Right now
Today
Past month
Past 6mos
Explain, if possible
Suicidal Thoughts
Right now
Today
Past month
Past 6mos
Explain, if possible
Any Specific Plan or History of Attempts (If so, explain)
Alcohol or Drug Use
Appetite/Sleep Disturbance
Tense or Nervous Feelings
Marital or Relationship Stressors
Problems at Work or School
Feelings of Anger
Excessive Worry or Unwanted Thoughts
Having to Do Certain Things Over and Over
Difficulty Concentrating
Depression/Sadness/Crying Spells
Loss of Interest/Enjoyment in Sexual Activity
Easily Annoyed or Irritated
Tempter Outbursts/Destruction of Property
Impulsive/Acting Without Thinking
History of Physical or Sexual Abuse
Feelings that Others are Out to Get You
Seeing Things That Others Do Not See
Hearing Things That Others Do Not Hear
Please explain any symptoms checked
What recent events/problems have brought about your request for help today?
Reviewed by Assessor/RN:
Date
MM slash DD slash YYYY
Time
:
Hours
Minutes
AM
PM
AM/PM
TB Health Questionnaire
I am tuberculin positive. I have had the recommended course of treatment for TB infection or disease.
I am tuberculin positive. I have had one negative chest x-ray since becoming TB skin positive.
I refuse the PPD/Mantoux Tuberculin Skin Test (TST)
HEALTH QUESTIONNAIRE
Please, answer the following (yes or no)
1. Have you been in contact with anyone with Tuberculosis?
YES
NO
2. Have you recently coughed up blood in your sputum?
YES
NO
3. Have you had an unintentional weight loss greater than 5lbs?
YES
NO
4. Have you had a recurrent fever of more than 100 degrees in the past month?
YES
NO
5. Have you had unusual sweating, especially at night?
YES
NO
6. Have you had any unexplained fatigue or weakness?
YES
NO
7. Have you been coughing for more than 3 weeks?
YES
NO
*If you answered yes to #7 coughing more than three weeks, AND yes to one or more of the above TB symptoms you will be evaluated by a Physician/LIP, to determine if a chest X-ray is indicated. Answering "yes" to any of the above questions suggests a higher risk of the presence of TB.
** If none of these symptoms are present, a chest X-Ray is not necessarily required; unless MD/LIP deems necessary or for future patient placement documentation.
Patient Signature
Date
MM slash DD slash YYYY
Nurse
Date
MM slash DD slash YYYY
CLOSE
Acknowledgement of Receipt of Notice of Privacy Practices
By signing this document, I acknowledge that I have received a copy of Palo Verde Behavioral Health's Notice of Privacy Practices and the Consumer Health Assistance Pamphlet.
Patient Name
First
Last
Signature
Date
MM slash DD slash YYYY
Patient Personal Representative
First
Last
Signature
Date
MM slash DD slash YYYY
Patient Medical Record Number or Social Security Number
Patient Birth Date
CLOSE
Conditions of Admission
1. MEDICAL/PSYCHIATRIC: The patient is under care of his/her attending physician/provider. The undersigned consents to any x-ray examination, laboratory procedures, anesthesia, psychiatric, medical or hospital services rendered the patient under the general and special instructions of the physician. The undersigned realizes that all doctors of medicine furnishing services to the patient including the radiologist, pathologist, anesthesiologist and the like may be independent contractors and not employees or agents of Palo Verde Behavioral Health. The undersigned understands that a physician/provider is not staffed on the premises 24-hours a day, but a physician/provider is on-call and may be reached 24-hours a day by Palo Verde Behavioral Health staff.
2. PERSONAL VALUABLES: Palo Verde Behavioral Health shall not be liable for the loss or damage to money, clothing, jewelry, dentures, or any other articles of value on or within Palo Verde Behavioral Health property. Palo Verde Behavioral Health shall not be liable for loss or damage to any other personal property.
3. CONTRABAND ITEMS: The undersigned agrees and understands that drugs, alcohol, weapons, or other articles specified as contraband by Palo Verde Behavioral Health may not be brought onto the premises, and that failure to abide by this rule could result in immediate discharge from Palo Verde Behavioral Health.
4. PHOTOGRAPHS: The undersigned hereby consents to the taking of a photograph for the purpose of identification. The photograph may be permanently retained in the patient's medical records. I understand that a patient identification wrist band may be used in lieu of a photograph. I understand the photograph will be used only for the purpose described, and will not be otherwise released without my express permission. Further, the undersigned acknowledges and is hereby informed that Palo Verde Behavioral Health uses real-time video surveillance and recording equipment on its premises. This equipment is uses solely for monitoring the t areas for safety.
5. VIOLENCE - ZERO TOLERANCE POLICY: I understand that Palo Verde Behavioral Health enforces a Zero-Tolerance policy regarding violence (verbal or physical), and that Palo Verde Behavioral Health has the right to pursue legal action against any person who engages in violence, either verbal or physical, against staff members, patients, visitors, or others while on the premises.
6. DISCHARGE AGAINST MEDICAL ADVICE: This is to certify that the patient assumes full responsibility for being discharged against the advice of the attending physician/provider and Palo Verde Behavioral Health administration, and hereby releases the attending physician, providers, therapist and Palo Verde Behavioral Health from all responsibility for any ill effects which may result from this action.
7. PROPERTY DAMAGE: Any damage to Palo Verde Behavioral Health property, caused by the patient, will be billed to the patient's account for the cost of repair or replacement, and must be paid in full on or before discharge.
8. ASSIGNMENT OF BENEFITS AND AUTHORIZATION TO RELEASE INFORMATION: In consideration of the services rendered, I hereby transfer and assign Palo Verde Behavioral Health all rights, titles, and interest in any payment due me for said services as provided by any and all policies of the insurance or other health care covered contract in which the patient is covered beneficiary. I further assign all right to payment due to medical services under said policies to the patient's attending practitioner and all consulting practitioners. I do hereby assign and transfer any and all Medicare/Medicaid benefits payable for outpatient services and practitioner services relating to this outpatient admission to Palo Verde Behavioral Health and the patient's attending consulting practitioners, therapist and hereby authorize Palo Verde Behavioral Health and said practitioners or practitioner organizations to submit claimers directly to Medicare/Medicaid for payment on behalf of the undersigned patient. I hereby authorize authorize Palo Verde Behavioral Health to release any information requested by said insurance company(s), its representatives, third party payers, or agencies as may be necessary to verify or process any and all claims for insurance coverage or third party reimbursement. I understand that such disclosures may contain information which could result in limitation or denial of insurance benefits or third party reimbursement. Nevertheless, each of the undersigned do hereby release and hold Palo Verde Behavioral Health, all agents and treating practitioners harmless of and from any and all costs, loss, damage or liability resulting from any such disclosure(s).
9. FINANCIAL AGREEMENT: The undersigned understands and agrees that Palo Verde Behavioral Health is not responsible for collecting insurance, or for resolving any disputed insurance or other third party payer claim, and promises unconditionally to pay Palo Verde Behavioral Health all costs and charges incurred in connection with the patient's hospitalization pursuant to this admission. It is agreed that if full payment is not made by insurance or other third party payers within thirty (30) days, the undersigned shall make payment in full. The undersigned acknowledged that failure to the outpatient services account may result in referral of said account to a commercial collection agency and/or credit bureau. Should the account be referred to any agency or attorney for collection, the undersigned shall pay reasonable attorney's fees and collection expenses.
10. PHYSICIAN/PROFESSIONAL SERVICES: Physicians/Providers will bill separately for their services. You may incur bill for specialized services provided by physicians/providers in the outpatient program other than your attending physician/provider. Acceptable payment arrangements must be made with their business office. Physician/Providers offices encourage communication so that you will have a clear understanding of their billing and collection policies.
10. PHYSICIAN/PROFESSIONAL SERVICES: Physicians/Providers will bill separately for their services. You may incur bill for specialized services provided by physicians/providers in the outpatient program other than your attending physician/provider. Acceptable payment arrangements must be made with their business office. Physician/Providers offices encourage communication so that you will have a clear understanding of their billing and collection policies.
ANY QUESTIONS OR CONCERNS REGARDING BILLING, INSURANCE, OR PAYMENT ARRANGEMENTS SHOULD BE DISCUSSED WITH OUR PATIENT ACCOUNT REPRESENTATIVES IN THE BUSINESS OFFICE AT (844)-884-CARE
The undersigned certifies that he/she has read the foregoing, received a copy thereof, and is the patient or parent/legal guardian if the patient is a minor, or is duly authorized by the patient as the patient's general agent to execute its terms.
Print Patient Name
Signature
Date/Time
Print Name of Guardian
Signature
Date/Time
CLOSE
Advance Directive
I have executed an Advance Directive for Medical Care
YES
NO
I have executed an Advance Directive for Mental Health Treatment
YES
NO
I have identified a Health Care Proxy/surrogate decision maker to make decisions on my behalf.
YES
NO
If yes, name of healthcare proxy/surrogate decision maker
Phone
Patient has a legal Guardian:
Name:
Phone
If you answered yes to any of the above, are you able to provide the facility with a copy of these Advance Directive Documents?
YES
NO
If you do not have an Advance Directive or Healthcare Proxy, do you wish to execute an advance directive or healthcare proxy or name a surrogate decision maker?
YES
NO
Patient Name
First
Last
Patient Signature
Date
MM slash DD slash YYYY
Time
:
Hours
Minutes
AM
PM
AM/PM
CLOSE
Consent for Treatment
Notice of privacy practices: I acknowledge receipt of Palo Verde Behavioral Health's Notice of Privacy Practices.
Medicare patients only: I acknowledge receipt of the written material entitled, "Important message from Medicare."
Acknowledge receipt of patient rights, important phone numbers, patient handbook, and dress code: I acknowledge that I have received these documents. My patient rights and the admission documents have been explained to me and I understand my rights and the admission documents.
Consent for treatment: I authorize Palo Verde Behavioral Health, its staff, and attending physicians to render to the patient all customary care, therapy, treatment, tests, and procedures considered advisable, including emergency treatment and transportation to another facility if necessary. Further consent is also given for any diagnostic procedures, medical treatment, x-ray treatment, recreational activities and therapy, and other treatment ordered by Hospital and/or attending physicians including but not limited to services provided by other Healthcare Professionals to the patient.
I affirm I have retained no medications on person and agree that all medications must be administered by a pharmacist or by a licensed nurse while a patient at the Hospital.
I understand the Hospital will not be responsible for the safety or care of the patient if the patient leaves the premises and will indemnify the Hospital for any loss or injury which may occur as a result of leaving against medical advice.
I understand that the use of reasonable restraint and/or confinement in accordance with, or as permitted by, applicable state law may be necessary, if severity of symptoms or behaviors warrants, in order to protect the patient from harming himself or others, or destroying property of the Hospital. Should such restraint and/or confinement become necessary during the patients' admission, I understand and agree to hold harmless the Hospital, its staff, physician, or other mental health professional, from any claim resulting from any loss due to injury that may occur as a result of such restraint and/or confinement.
I authorize the staff to notify my family of any seclusion or restraining episode
YES
NO
Guardian/significant other
Phone
I acknowledge that the patient is under the control of an attending physician(s) and the Hospital is not liable for any act or omission in following the instructions of said physicians. The undersigned recognizes that certain healthcare professionals furnishing services to the patient, including, but not limited to, radiologists, pathologists, psychologists, physical therapists and/or licensed social workers may be independent contractors and may not be employees or agents of the Hospital. The undersigned further recognizes that the patient may be billed separately by their attending physicians and/or other healthcare professionals for their services provided.
Consents for admissions: I acknowledge that no guarantee or assurance has been made, as to the results of any services provided including, but not limited to, therapy, treatment, tests or procedures, while admitted to the Hospital. I further understand that, unless otherwise disclosed the Hospital does not employ physicians and that the patients admitting physician and any other physician who may consult or provide services to the patient during this admission are not employed by and are not agents of the Hospital, but are independent physicians who exercise their judgement in the services they render.
I acknowledge that Palo Verde Behavioral Health is a teaching facility and that professional students may have patient contact and access to the patient's medical record information. Students providing direct patient care are subject to the Hospital's orientation and training requirements. These students are supervised by a licensed professional and are required to meet the hospital confidentiality standards.
I authorize the Hospital to search the personal belongings when it is reasonably believed that there may be or is in possession of an item or items which may be dangerous to his/her health or to the health of others. If any are found, it is understood that they will be maintained in a secure place and returned to the patient at discharge unless otherwise therapeutically indicated by the attending physician.
I consent to the taking of photograph(s) for the purpose of identification. This photograph(s) may be permanently retained in the medical record.
I release the Hospital from any liability for the loss or damage of personal property and money. Any property left behind at the time of discharge will be disposed of after 15 days. The hospital assumes no liability for loss or damage to vehicles parked on hospital premises. Patients are encouraged NOT to leave personal vehicles on premises.
Consent to acknowledge your presence: I acknowledge that Palo Verde Behavioral Health will not release my patient health information unless the Hospital has a release or authorization to do so or as authorized under federal or state law. I will be given a confidential Identification Number to be used for acknowledgement. I hereby give my permission to accept mail without the ID Number. Furthermore, I consent to allow Palo Verde Behavioral Health to inform the patient's attending physician and/or referral sources of the admission to and progress at Palo Verde Behavioral Health.
Telemedicine Services: Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education.
Network and software security protocols will be implemented to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Expected Benefits: • Improved access to medical care by enabling a patient to remain in the hospital while the provider provides service from another location • More efficient medical evaluation and management • Obtaining expertise of a distant specialist
Possible Risks: As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to: • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider; • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information, or • In rare cases, a lack of access to complete medical records may result in adverse drug reactions.
Responsibility for destruction of property: I understand that I am responsible for any damage to or destruction of Hospital property, or property belonging to others which may be located at the Hospital. I agree to accept liability for, and reimburse the Hospital or other owner of property, I may damage or destroy.
Acknowledge receipt of patient advocacy policy: I acknowledge that a copy of the Patient & Family Grievances/The Role of the Patient Advocate policy has been given to me. The policy has been explained and I understand this policy.
Discharge policy information: I understand that it is the policy of the Hospital to attempt to provide a structured therapy regimen with effective quality treatment. If the treatment regimen is not completed prior to the exhausting of health insurance benefits; I agree to be liable for any charges incurred which are not paid by insurance in addition to the deductible and/or co-payment liability. It is NOT Hospital policy to discharge or transfer patients or end treatment regimens simply because insurance benefits have been exhausted.
Release of Information: On the Palo Verde Behavioral Health Consent To Release Information form, I authorize the Hospital to release any information or records contained in hospital patient records related to alcohol or substance abuse diagnosis or treatment, mental health treatment, or any communicable disease, including HIV/AIDS to (a) any of my treating practitioners, (b) my insurance company or health plan, (c) any other person or entity that is responsible for paying or processing for payment my hospital bill, (d) any other health care provider to which I am transferred for care, (e) entities using this information for quality management and peer review, and (f) any other writing, of my desire to revoke it or according to the date or condition of expiration specified on the Palo Verde Behavioral Health Consent to Release Information form.
Clinical Staff: Clinical Staff may be provided clinical supervision while performing their duties. As part of this supervision, the clinical supervisor has the same access to the patient charts as the Clinical Staff, will be reviewing patient charts with the clinical staff, and will be sitting in on patient activities. The clinical supervisor is bound by the same State and Federal laws of confidentiality as the Clinical Staff at Palo Verde. If you wish to know the name of or speak to the clinical supervisor, please contact the Patient Advocate at 520-322-2867.
Inpatient Hospital Charges: $2150.00 IP per day includes room, board, nursing care, family, group, multifamily, activity, recreation and use of all the facilities. Outpatient Charges: $1250.00 PHP per day, $750.00 per day. Professional component is billed separately.
Resolution of overpayment: If a payment results in a credit balance (overpayment) and is an improper or excessive payment made, the credit balance will be researched and if appropriate, a refund will be issued by check within 30 days to the appropriate party. In the case of Medicare overpayments, these shall be entered on the quarterly credit balance sheet.
Guarantee of payment: I guarantee the payment of the bill for services rendered by Palo Verde Behavioral Health. I agree whether signing as guarantor or as patient, that in consideration of the services to be rendered to the patient, to be hereby jointly and individually obligated to pay the account(s) of the Hospital in accordance with the regular rates and terms of the Hospital. I understand I am responsible for all health insurance co-payments and deductibles. Should the account be referred for collection by an attorney or collection agency, the undersigned agree(s) to pay all attorney's fees and other reasonable collection costs and charges that are necessary for the collection of any amount(s) not paid when due. I give permission to run a credit report on the guarantor or insured party if payment arrangements are requested on any accounts with Palo Verde Behavioral Health.
Assignment of insurance benefits: In consideration of hospital and medical services rendered or to be rendered by Palo Verde Behavioral Health, to the extent permitted by law, I hereby (I) irrevocably assign, transfer and set over to Palo Verde Behavioral Health (II) all of my rights, title and interest to medical reimbursement, including, but not limited to, (III) the right to designate a beneficiary, add dependent eligibility and (IV) to have an individual policy continued or issued in accordance with the terms and benefits under any insurance policy, subscription certificate or other health benefit indemnification agreement otherwise payable to me for those services rendered by Palo Verde Behavioral Health during the pendency of the claim for this admission. Such irrevocable assignment and transfer shall be for the recovery on said policy or policies of insurance, but shall not be construed to be an obligation of Palo Verde Behavioral Health to purse any such right of recovery. I hereby authorize the insurance company or companies, or third party payor(s) to pay directly to Palo Verde Behavioral Health all benefits due for services rendered. Under this assignment, Hospital shall have the right to appeal any denied or delayed claims on behalf of the insured or beneficiary.
Insufficient insurance coverage: I understand if my insurance or other third party coverage rejects the claim or pays only part of the claim, then I will be responsible for payment of the balance due, as determined by the Hospital or other Healthcare Professional.
Primary/Secondary Insurance coverage: I understand it is my responsibility to furnish the Hospital with all of my insurance policies in order to authorize my care. I understand if I did not provide all insurance information at the time of admission, I will be responsible for any amounts not paid by either carrier, including but not limited to denied days due to no pre authorizations.
Insured employer: On the Palo Verde Behavioral Health Consent to Release Information form, I authorize Palo Verde Behavioral Health to release and to obtain information from the Insured and/or Insured's Employer of the policy, regarding employment, verification of insurance coverage, benefits or any other information necessary to process the insurance claim.
I acknowledge that the above information has been read and understood.
Patient's Name
Patient's Signature
Date
MM slash DD slash YYYY
Admission Time
:
Hours
Minutes
AM
PM
AM/PM
Signature of Insured/Guarantor
Date
MM slash DD slash YYYY
Signature of Legal Guardian - Next of Kin
Date
MM slash DD slash YYYY
Signature of Insured/Co-Guarantor
Date
MM slash DD slash YYYY
Signature of Hospital Staff
Date
MM slash DD slash YYYY
CLOSE
Insurance Information
Today's Date
MM slash DD slash YYYY
Primary Insurance Carrier
Policy Number
Group Number
Effective Date
MM slash DD slash YYYY
Policy Holder's Name
First
Middle
Last
Relationship to Patient
Policy Holder's Date of Birth
MM slash DD slash YYYY
Policy Holder's Social Security Number (SS#)
Policy Holder's Home Phone
Policy Holder's Cell Phone
Policy Holder's Work Phone
Secondary Insurance Carrier
Policy Number
Group Number
Effective Date
MM slash DD slash YYYY
Policy Holder's Name
First
Middle
Last
Policy Holder's Home Phone
Policy Holder's Date of Birth
MM slash DD slash YYYY
Policy Holder's Work Phone
Policy Holder's Social Security Number (SS#)
Policy Holder's Cell Phone
Have you recently lost employment tied to this insurance?
YES
NO
Is your insurance coverage provided under the terms of Cobra?
YES
NO
Do you have any other health insurance?
YES
NO
Acknowledgement
I acknowledge that the information provided above is accurate and complete to the bet of my knowledge.
Signature
Date/Time
CLOSE
Patient Authorization for disclosure of PHI
Select all that apply
Primary Care Provider
Psychiatrist
Therapist
Patient Name
First
Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
I hereby freely and voluntarily authorize Desert Mountain Outpatient Services to (check box below):
Release/disclose my protected health information to:
Obtain my protected health information from:
Name
First
Last
Relationship to Patient
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Fax
This information is necessary for:
**Indicates Fee for Service (Cost based on page count)
Follow-up Care- (Discharge packet only)
Patient Request / Personal**
Attorney
Legal**
Disability Benefits**
Other**
(Explain):
Please disclose the following:
Physician Progress Note(s)
History & Physical
Psychiatric Evaluation
Psycho Social
Discharge Summary
Treatment Plan
Medication List
Lab Results
Face sheet
After-Care Packet
Leave of Absence Request
Complete Chart
Other
(Explain):
Date(s) of Service:
I give special permission to release any information regarding items listed below:
Alcohol, Drug, or Substance abuse Records
YES
NO
Initials
HIV / AIDS Medical Information
YES
NO
Initials
Please disclose my information via:
FAX
MAIL
PICK-UP
VERBAL
Patient Signature or Authorized Representative (Guardian)
Date
MM slash DD slash YYYY
Time
:
Hours
Minutes
AM
PM
AM/PM
Relationship to Patient
Witness
Date
MM slash DD slash YYYY
Time
:
Hours
Minutes
AM
PM
AM/PM
Relationship to Patient
Patient Signature or Authorized Representative (Guardian)
Date
MM slash DD slash YYYY
Time
:
Hours
Minutes
AM
PM
AM/PM
Relationship to Patient
Witness
Date
MM slash DD slash YYYY
Time
:
Hours
Minutes
AM
PM
AM/PM
Relationship to Patient
CLOSE
Patient Information
Patient Information
Name
First
Middle
Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Marital Status
Single
Married
Separated
Divorced
Widow
Gender
Male
Female
Transgender
Other
SS#
Home Phone
Cell Phone
Work Phone
Email
I give consent to receiving emails
YES
NO
Employer
Employer’s Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Family Physician (PCP) Name
Family Physician (PCP) Phone
Psychiatrist Name
Psychiatrist Phone
Parent/Spouse/Guardian Information
Check which applies
Parent
Spouse
Guardian Information
Name
First
Middle
Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
SS#
Home Phone
Cell Phone
Work Phone
Employer
Employer’s Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Insurance Information
Please give your insurance card and photo ID to Receptionist
Primary Insurance Carrier
Policy Number
Group Number
Effective Date
MM slash DD slash YYYY
Policy Holders Name
First
Middle
Last
Relationship to Patient
Policy Holders Date of Birth
MM slash DD slash YYYY
Policy Holders Social Security Number (SS#)
Policy Holders Home Phone
Policy Holders Cell Phone
Policy Holders Work Phone
Secondary Insurance Carrier
Policy Number
Group Number
Effective Date
MM slash DD slash YYYY
Policy Holders Name
First
Middle
Last
Relationship to Patient
Policy Holders Date of Birth
MM slash DD slash YYYY
Policy Holders Social Security Number (SS#)
Policy Holders Home Phone
Policy Holders Cell Phone
Policy Holders Work Phone
Have you recently lost employment tied to this insurance?
YES
NO
Is your current coverage provided under the terms of Cobra?
YES
NO
Do you have any other health insurance?
YES
NO
Acknowledgement
I acknowledge that the information provided above is accurate and complete to the best of my knowledge.
Signature
Date
MM slash DD slash YYYY
Time
:
Hours
Minutes
AM
PM
AM/PM
CLOSE
Release of Information
Patient Name
First
Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
I hereby freely and voluntarily authorize Palo Verde Behavioral Health to (check box below):
Release/disclose my protected health information to:
Obtain my protected health information from:
Name
First
Last
Relationship to Patient
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Fax
This information is necessary for:
Follow-up Care- (Discharge packet only)
Patient Request / Personal**
Attorney / Legal**
Disability Benefits**
Other ** (explain):
**Indicates Fee for Service (Cost based on page count)
Please disclose the following:
Physician Progress Note(s)
History & Physical
Psychiatric Evaluation
Psycho Social
Discharge Summary
Treatment Plan
Medication List
Lab Results
Face sheet
After-Care Packet
Leave of Absence Request
Complete Chart
Other (explain)
Date(s) of Service
I give special permission to release any information regarding items listed below:
Alcohol, Drug, or Substance abuse Records
YES
NO
Initial
HIV / AIDS Medical Information
YES
NO
Initial
Please disclose my information via
FAX
MAIL
PICK-UP
VERBAL
• Requests for copies of medical records are subject to Fee for Service in accordance with federal/state regulations.
• I have the right to REVOKE this authorization at any time. I can revoke this authorization during my stay, please specify below.
• After I discharge, revocation must be made in writing and presented to the Health Information Management Department at the following address: 2695 N. Craycroft Rd, Tucson, AZ 85712. Revocation will not apply to information that has already been disclosed in response to this authorization.
• This authorization will expire one year from the date signed unless otherwise specified (Otherwise specified date ).
• Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization.
• Any disclosure of information carries with it the potential for unauthorized re-disclosure.
• Copy of driver’s license or identification card must accompany all requests.
Otherwise specified date
*****THIS AUTHORIZATION FORM IS ONLY VALID WHEN FULLY COMPLETED*****
Patient Signature or Authorized Representative (Guardian)
Date
MM slash DD slash YYYY
Time
:
Hours
Minutes
AM
PM
AM/PM
Relationship to Patient
Witness
Date
MM slash DD slash YYYY
Time
:
Hours
Minutes
AM
PM
AM/PM
Relationship to Patient
This Authorization has been revoked effective:
Patient Signature or Authorized Representative (Guardian)
Date
MM slash DD slash YYYY
Time
:
Hours
Minutes
AM
PM
AM/PM
Relationship to Patient
Witness
Date
MM slash DD slash YYYY
Time
:
Hours
Minutes
AM
PM
AM/PM
Relationship to Patient
CLOSE
