INSURANCE INFORMATION

PRIMARY INSURANCE POLICY HOLDER INFORMATION

SECONDARY INSURANCE POLICY HOLDER INFORMATION (OPTIONAL)

DISCLAIMER: THE PRACTITIONERS AT VALOR HEALTH & WELLNESS ARE INDEPENDENT OF EACH OTHER IN THEIR PRACTICE OR PROFESSIONAL SERVICE. CLAIMS, EITHER IMPLIED OR EXPRESSED, AGAINST THE CLINIC OR THE PRACTITIONERS WILL NOT BE ADDRESSED OTHER THAN THOSE BETWEEN THE PATIENT AND HIS/HER NP, PA OR PSYCHIATRIST.

I CONSENT TO FULL RESPONSIBILITY FOR PAYMENT OF THESE SERVICES AND AGREE TO PAY THEM IN FULL AT THE TIME OF SERVICE, UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE WITH MY INSURANCE OR PROVIDER.

I CONSENT TO FULL RESPONSIBILITY FOR PAYMENT OF MISSED APPOINTMENTS WHEN NO NOTICE OF CANCELLATION IS MADE 24 HOURS IN ADVANCE. ALSO CONSENT TO PAYMENT FOR A FEE OF $50 IF COLLECTION ACTION IS NECESSARY TO COLLECT ON ANY UNPAID BALANCES ON MY ACCOUNT.

LIST ALL CURRENT MEDICATIONS

Valor Health & Wellness Authorization

• I authorize use of this form on all my insurance submissions.

• I authorize release of Information to all my insurance companies.

• I understand that I am responsible for my bill (cash pay, deductible and/or copay included).

• I authorize billing for late fees and cancellation fees.

• I authorize billing for Tele-health/Tele-psychiatry visits.

• I authorize my health care provider to act as my agent in obtaining payment from my insurance company.

• I authorize direct payment to my health care provider.

• I permit a copy of this authorization to be used in place of the original.

Health insurance Portability & Accountability Act (HIPAA) Privacy Acknowledgment Form

IMPORTANT NOTICE TO ALL PATIENTS

At Valor Health & Wellness, we are committed to providing you with high-quality mental health services. To ensure a smooth and efficient payment process, we have certain financial procedures in place. Please take note of the following information:

We bill usual and customary fees for standard services offered.

Additional services not covered by insurance companies include:

1. FMLA, long term medical leave/extensive forms: $50.00

2. Short medical leave, short-term leave forms: $25.00

3. Late cancel without a 24-hour notice or No-show fee: $50.00

4. Returned check fee: $35.00

5. Medical record copying will be charged according to State of Michigan rates.

I understand payment for services is due at the time the services are rendered. I understand deductibles and co-pays applicable to my policy is best explained by my insurance provider, but is the responsibility of the patient.

Credit Card Information: Valor Health & Wellness may require patients to provide credit card information prior to their appointment. This is to ensure that any deductibles determined by your insurance can be covered at the time of your appointment if necessary. Rest assured that your credit card information will be securely stored and processed in compliance with all relevant regulations.

Payment Options: We offer various payment options for your convenience. You have the choice to pay via:

1. Credit Card: Your credit card on file will be charged for any applicable deductibles determined by your insurance at the time of your appointment.

2. Cash: You may pay in cash if that is your preferred method of payment. Please inform the staff at Valor Health & Wellness if you intend to pay in cash.

I understand that Valor Health & Wellness reserves the right to any outside collection agency as a means of collecting any outstanding balances, if my account remains unpaid or payment arrangements are not made. I understand that if my account goes to collections, I will be charged an additional $50.00.

I understand it is my responsibility to keep scheduled appointments or notify Valor Health & Wellness staff 24 hours prior to the scheduled appointment time or be charged a $50.00 no show fee. This fee is due at the next scheduled appointment and cannot be billed to your insurance carrier.

Fees are subject to change without notice.

For patients not utilizing insurance, usual and customary fees set forth by Valor Health & Wellness apply unless a different rate has otherwise been specified. Furthermore, a good-faith estimate is posted on www.valorhw.com and is available at each practice for patients use.

By signing below, I acknowledge that I have read, understand, and agree with the financial conditions described above. I understand that Valor Health & Wellness may require my credit card information and that I have the option to choose my preferred payment method.

Authorization for Release of Information to Family Members

Many of our patients allow family members such as their spouse, parents, or others to call and request medical or billing information. Under the requirements of HIPAA, we are not allowed to give this information to anyone without the patient's consent. If you wish to have your medical or billing information released to family members you must sign this form. Signing this form will only give information to family members names indicated below.

I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed. I understand that information disclosed to any authorized recipient is no longer protected by federal or state law and may be subject to re disclosure by the above recipient. You have the right to revoke this consent in writing at any time.

I authorize Valor Health & Wellness to release my medical and/or billing information to the following individual(s):

PATIENT FEES AND PAYMENT AGREEMENT

At Valor Health & Wellness, we are committed to providing you with high-quality mental health services. To ensure a smooth and efficient payment process, we have certain financial procedures in place. Please take note of the following information:

We bill usual and customary fees for standard services offered.

Additional services not covered by insurance companies include:

FMLA, long term medical leave/extensive forms: $50.00

Short medical leave, short-term leave forms: $25.00

Late cancel without a 24-hour notice or No-show fee: $50.00

Returned check fee: $35.00

Medical record copying will be charged according to State of Michigan rates.

I understand payment for services is due at the time the services are rendered. I understand deductibles and co-pays applicable to my policy is best explained by my insurance provider, but is the responsibility of the patient.

Credit Card Information: Valor Health & Wellness may require patients to provide credit card information prior to their appointment. This is to ensure that any deductibles determined by your insurance can be covered at the time of your appointment if necessary. Rest assured that your credit card information will be securely stored and processed in compliance with all relevant regulations.

Payment Options: We offer various payment options for your convenience. You have the choice to pay via:

Credit Card: Your credit card on file will be charged for any applicable deductibles determined by your insurance at the time of your appointment.

Cash: You may pay in cash if that is your preferred method of payment. Please inform the staff at Valor Health & Wellness if you intend to pay in cash.

Check: If you prefer to pay by check, please let our staff know in advance, and arrangements will be made to accept your payment.

Other Digital Payment Methods: We understand that you may have other digital payment preferences. If you wish to use an alternative digital payment method, please notify the staff at Valor Health & Wellness in advance so that necessary arrangements can be made.

I understand that Valor Health & Wellness reserves the right to any outside collection agency as a means of collecting any outstanding balances, if my account remains unpaid or payment arrangements are not made. I understand that if my account goes to collections, I will be charged an additional $50.00.

I understand it is my responsibility to keep scheduled appointments or notify Valor Health & Wellness staff 24 hours prior to the scheduled appointment time or be charged a $50.00 no show fee. This fee is due at the next scheduled appointment and cannot be billed to your insurance carrier.

Fees are subject to change without notice.

For patients not utilizing insurance, usual and customary fees set forth by Valor Health & Wellness apply unless a different rate has otherwise been specified. Furthermore, a good-faith estimate is posted on www.valorhw.com and is available at each practice for patients use.

By signing below, I acknowledge that I have read, understand, and agree with the financial conditions described above. I understand that Valor Health & Wellness may require my credit card information and that I have the option to choose my preferred payment method.

TELEPSYCHIATRY PATIENT CONSENT FORM

Telepsychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems between a provider and a patient that are not in the same physical location. These services may also include electronic prescribing, appointment scheduling, communication via email or electronic chat, electronic scheduling, and distribution of patient education materials.

The potential benefits of telepsychiatry are:

• Reduced wait time to receive psychiatric care.

• Avoiding the need to travel to a psychiatrist.

The potential risks of telepsychiatry include, but are not limited to:

• There could be some technical problems (video quality, internet connection) that may affect the telepsychiatry session.

Valor Health & Wellness utilizes software that meets the recommended standards to protect the privacy and security of the telepsychiatry sessions.

Alternatives to the use of telepsychiatry:

• Traditional face-to-face sessions.

I understand that I have the following rights with respect to telepsychiatry:

1. The laws that protect the confidentiality of my medical information also apply to telepsychiatry. As such, I understand that the information disclosed by me during the course of my treatment is confidential However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.

2. I understand that the dissemination of any personally identifiable images or information from the telepsychiatry interaction to researchers or other entities shall not occur without my written consent.

3. I understand that there are risks and consequences from telepsychiatry, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychiatrist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

4. I understand that telepsychiatry based services and care may not be as complete as face-to-face services. I also understand that if my psychiatrist believes I would be better served by another form of psychiatric services (e.g. face-to- face services) will be referred to a psychiatrist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychiatry.

5. I understand that have a right to access my medical information and copies of medical records in accordance with Michigan Law.

Patient's Responsibilities:

• I will not record any telepsychiatry sessions without written consent from my provider. I understand that my provider will not record any of our telepsychiatry sessions without my written consent.

• I will inform my provider if any other person can hear or see any part of our session before the session begins. The provider will inform me if any other person can hear or see any part of our session before the session begins.

• I understand that I, not my provider, am responsible for the configuration of any electronic equipment used on my computer that is used for telepsychiatry. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins.

• I understand that my psychiatrist determines whether or not the condition being diagnosed and/or treated is appropriate for a telepsychiatry encounter.

• I understand that if the telepsychiatry session does not achieve everything that is needed, then I will be given a choice about what to do next. This could include a follow up face-to-face visit, or a second telepsychiatry visit.

• I understand that post COVID-19 it is my responsibility to contact my insurance company to verify telepsychiatry coverage.

By signing below, I confirm that I have verified my behavioral health benefits with my insurance company and that telehealth is a covered benefit under my insurance plan. If not, I understand that I am responsible for the cost of any telehealth visit not covered by my insurance company.

Patient Consent to The Use of Telepsychiatry:

I hereby consent to engaging in telepsychiatry with Valor Health & Wellness as part of my psychiatric evaluation and treatment. I understand that "telepsychiatry" includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I have read and understand the information provided above regarding telepsychiatry.

PICTURE ID AND INSURANCE CARD

If you want to upload images or don't have a camera on your device: click "Take Photo", then when asked permission to use camera select no/don't allow. The "take photo" becomes "Use Photo" and will allow you to use a picture from your device.

Credit Card Authorization:

If no credit card available or other payment method requested, please be ready to provide this information at time for scheduling appointment.