New Patient Enrollment Form

The form below is our New Patient Enrollment Form. Before you fill that out and submit, please read the Privacy Practices information below.

Fields with an * are required.

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

PRIVACY PRACTICES ACKNOWLEDGEMENT FORM

Patient First Name:

Patient Middle Initial:

Patient Last Name:

Patient Suffix: (Sr, Jr, etc.)

Date of Birth:

Relationship to Patient:

Guardian Disclaimer:

Yes, I understand that I will need to provide proof of Guardianship

Power of Attorney Disclaimer:

Yes, I understand that I will need to provide proof of Power of Attorney

If other, describe relationship to patient here:

I have read and agree to the Terms and Conditions and Privacy Policy below:

NOTICE OF PRIVACY PRACTICES MICHAEL FRAMPTON, M.D., P. C . & ASSOCIATES
9120 CONNECTICUT, SUITE A MERRILLVILLE, IN 48410 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This notice takes effect on 04/14/03 and remains in effect until we replace it.

1. OUR PLEDGE REGARDING MEDICAL INFORMATION

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information.

2. OUR LEGAL DUTY

Law Requires Us to: 1. Keep your medical information private. 2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information. 3. Follow the terms of the notice that is now in effect. We Have the Right to: 1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law. 2. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes. Notice of Change to Privacy Practices: 1. Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.

3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION

The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us. FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other geople who are taking care of you. We may also share medical information about you to your other health care providers to assist them in treating you. FOR PAYMENT: We may use and disclose your medical information for payment purposes. FOR HEALTH CARE OPERATIONS: We may use and disclose your medical information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you. NOTICE OF PRIVACY PRACTICES ADDITIONAL USES AND DISCLOSURES: In addition to using and disclosing your medical information for treatment, payment, and health care operations, we may use and disclose medical information for the following purposes. Facility Directory: Unless you notify us that you object, the Toliowing medical information about you will be placed in our facilities' directories: your name; your location in our facility; your condition described in general terms; your religious affiliation, if any. We may disclose this information to members of the clergy or, except for your religious affiliation, to others who contact us and ask for information about you by name. Notification: Medical information to notify or help notify: a family member, your personal representative or another person responsible for your care. We will share information about your location, general condition, or death. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-ray or medical information for you. Disaster Relief: Medical information with a public or private organization or person who can legally assist in disaster relief efforts. Fundraising: We may provide medical information to one of our affiliated fundraising foundations to contact you for fundraising purposes. We will limit our use and sharing to information that describes you in general, not personal, terms and the dates of your health care. In any fundraising materials, we will provide you a description of how you may choose not to receive future fundraising communications. Research in Limited Circumstances: Medical information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical information. Funeral Director, Coroner, Medical Examiner: To help them carry out their duties, we may share the medical information of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization. Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits. Court Orders and Judicial and Administrative Proceedings: We may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials. We may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person. We may share the medical information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances. Public Health Activities: As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to track products, or to conduct activities required by the Food and Drug Administration. We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition. NOTICE OF PRIVACY PRACTICES Victims of Abuse, Neglect, or Domestic Violence: We may disclose medical information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may share your medical information if it is necessary to prevent a serious threat to your health or safety or the health or safety of others. We may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody. Workers Compensation: We may disclose health information when authorized and necessary to comply with laws relating to workers compensation or other similar programs. Health Oversight Activities: We may disclose medical information to an agency providing health oversight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities. Law Enforcement: Under certain circumstances, we may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.

4. YOUR INDIVIDUAL RIGHTS

You Have a Right to: 1. Look at or get copies of your medical information. You may request that we provide copies in a format other than photocopies. We will use the format you request unless it is not practical for us to do so. Yo u must make your request in writing. You may get the form to request access by using the contact information listed at the end of this notice. You may also request access by sending a letter to the contact person listed at the end of this notice. If you request copies, we will charge you per Indiana law for each page, and postage if you want the copies mailed to you. Contact us using the information listed at the end of this notice for a full explanation of our fee structure. 2. Receive a list of all the times we or our business associates shared your medical information for purposes other than treatment, payment, and health care operations and other specified exceptions. 3. Request that we place additional restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency). 4. Request that we communicate with you about your medical information by different means or to different locations. Your request that we communicate your medical information to you by different means or at different locations must be made in writing to the contact person listed at the end of this notice. 5. Request that we change your medical information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information. 6. If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing to the Privacy Officer at your office.

QUESTIONS AND COMPLAINTS

If you have any questions about this notice or if you think that we may have violated your privacy rights, please contact us. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint.

Patient Signature:

Type your name exactly as the Patient's Name field to represent your signature. If you are under 18, a parent or guardian must sign this form.

Today's Date:

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

PATIENT INFORMATION

Patient First Name:

Patient Middle Initial:

Patient Last Name:

Patient Suffix: (Sr, Jr, etc.)

Social Security #:

Enter Social Security #:

No Social Security #

Confirm: I do not have a Social Security #

Your Home Address:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Mailing Address: (If different from Home address)

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Mobile Phone:

Home Phone:

Work Phone:

Always use this number first: (Enter phone number)

Date of Birth:

Age:

Gender:

Marital Status:

Employer Name:

Employer Phone:

Employer Address:

Address Line 1

Address Line 2

City

State

Zip Code

EMERGENCY CONTACT PERSON

First Name:

Last Name:

Contact Phone:

Relationship to Patient:

Guardian Disclaimer:

Yes, I understand I that I will need to provide proof of Guardianship

Power of Attorney Disclaimer:

Yes, I understand that I will need to provide proof of Power of Attorney

If other, describe relationship to patient:

REQUIRED: RESPONSIBLE FINANCIAL PARTY INFORMATION

First Name:

Last Name:

Social Security #:

Relationship to Patient:

Guardian Disclaimer:

Yes, I understand I that I will need to provide proof of Guardianship

Power of Attorney Disclaimer:

Yes, I understand that I will need to provide proof of Power of Attorney

If other, describe relationship to patient:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address: (If different from home address)

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone:

Date of Birth:

Employer Name:

Employer Phone:

Employer Address:

Address Line 1

Address Line 2

City

State

Zip Code

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

PRIMARY INSURANCE INFORMATION

Primary Insurance Status:

If you have primary insurance, please fill out the fields below.

IF YOU DO NOT WANT TO USE YOUR PRIMARY INSURANCE, PLEASE CHECK THIS BOX AND CONTINUE TO THE NEXT SECTION

I am self pay

Insurance Company Name:

Insurance Company Phone:

Policy Number:

First Name:

Middle Initial:

Last Name:

Suffix (Sr, Jr, etc.)

Social Security #:

Date of Birth:

Relationship to Patient:

Guardian Disclosure:

Yes, I understand that I will need to provide proof of Guardianship

Power of Attorney Disclosure:

Yes, I understand that I will need to provide proof of Power of Attorney

If other, describe relationship to patient:

Insurance Company Address:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Employer Name:

Employer Phone:

Employer Address:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

SECONDARY INSURANCE INFORMATION

Secondary Insurance Status:

If you have secondary insurance, please fill out the fields below.

IF YOU DO NOT WANT TO USE YOUR SECONDARY INSURANCE, PLEASE CHECK THIS BOX AND CONTINUE TO THE NEXT SECTION

I am self-pay

Secondary Insurance Company Name:

Secondary Insurance Company Phone:

Secondary Insurance Policy Number:

First Name:

Middle Initial:

Last Name:

Suffix (Sr, Jr, etc.)

Social Security #:

Date of Birth:

Relationship to Patient:

Guardian Disclosure:

Yes, I understand that I will need to provide proof of Guardianship

Power of Attorney Disclosure:

Yes, I understand that I will need to provide proof of Power of Attorney

If other, describe relationship to patient:

Employer Name:

Employer Phone:

Secondary Insurance Company Address:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

TREATING PRIMARY CARE PHYSICIAN

Primary Care Physician Name

Primary Care Physician Phone:

Primary Care Physician Address:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

REFERRING THERAPIST OR PHYSICIAN

Referring Therapist or Physician Name

Referring Therapist or Physician Phone:

Referring Therapist or Physician Address:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

RECORD OF PREVIOUS TREATMENT

Physician or Facility:

Physician or Facility Phone:

Physician or Facility Address:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Date(s) of Treatment:

Physician or Facility:

Physician or Facility Phone:

Physician or Facility Address:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Date(s) of Treatment:

Physician or Facility:

Physician or Facility Phone:

Physician or Facility Address:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Date(s) of Treatment:

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

CONSENT FOR TREATMENT

First Name:

Middle Initial:

Last Name:

request treatment as a patient of Michael Frampton M.D., P.C. and/or other providers and voluntarily consent to such care and routine diagnostic procedures and medical treatment by the physician and his assistants or designee as is necessary in the physician’s judgement. I am aware that the practice of psychiatry is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatment or examination in the clinic. I understand that if the patient appears to be dangerous to himself/herself or others the staff will exercise the necessary interventions in order to protect the patient or others.

Choose one of the options:

Patient Signature: (Type your name to agree)

Today's Date:

Responsible Person's Signature: (Type your name to agree)

Today's Date:

Relationship to Patient:

Guardian Disclaimer:

Yes, I understand that I will need to provide proof of Guardianship

Power of Attorney Disclaimer:

Yes, I understand that I will need to provide proof of Power of Attorney

If other, describe relationship to patient

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

STATEMENT OF FINANCIAL RESPONSIBILITY

AUTHORIZATION TO RELEASE INFORMATION TO THIRD PARTY PAYERS
I have provided Michael Frampton M.D., P.C. and/or other providers with the information regarding eligibility and benefits. I understand that this authorization will be used by Michael Frampton M.D., P.C. and named insurance company to determine the eligibility and benefits under the existing policy. Any information obtained will not be released by the insurance company without authorization. This authorization shall be valid during the pending of the claim unless specifically revoked in writing.

ASSIGNMENT OF INSURANCE BENEFITS
I hereby authorize payment of benefits others payable to me to be paid to Michael Frampton M.D., P.C. I authorize insurance companies providing coverage for services to make payment directly to Michael Frampton M.D., P.C. The insurance will be verified but is not guaranteed.

GUARANTEE OF PAYMENT
I guarantee payment of the bill for services provided. I understand that I am financially responsible to Michael Frampton M.D., P.C. for charges not covered or paid by the insurance company. I agree to pay my out of pocket money at the time of my visits. If my insurance needs to be pre-certified I will be responsible for pre-certifying my insurance. I understand that if I do not pre-certify I will be responsible for the bill.

CHANGE OF INSURANCE
If your insurance policy changes, please notify our office immediately. We must have enough advance notice in order to verify your benefits prior to your next scheduled visit. If we are unable to verify your benefits or you fail to give us reasonable time to call on your benefits, you will be responsible for the entire charge of the visit(s).

NO-SHOW FEE
Failure to cancel at least 24 hours before your scheduled appointment will result in a no-show fee. This fee will not be billed to your insurance company and must be paid before your next appointment with Michael Frampton M.D., P.C. and all other providers associated with Michael Frampton M.D., P.C.

Time spent with Dr. Frampton and/or other providers outside of scheduled sessions answering patient phone calls, writing prescription renewals or letters, completing forms, etc, will be billed directly to the patient and not to the insurance company.

Choose one of the options:

Patient Signature: (Type your name to agree)

Today's Date:

Responsible Person's Signature: (Type your name to agree)

Today's Date:

Relationship to Patient:

Guardian Disclaimer:

Yes, I understand that I will need to provide proof of Guardianship

Power of Attorney Disclaimer:

Yes, I understand that I will need to provide proof of Power of Attorney

If other, describe relationship to patient

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

NEW PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS

I, the undersigned: (Type your name to agree)

Today's Date:

understand that as part of my healthcare, Michael Frampton M.D., P.C., originates and maintains paper and/or electronic records describing my health history, symptoms, examinations and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment
A means of communication among the many health professionals who contribute to my care
A source of information for applying my diagnosis and surgical information to my bill
A means by which a third-party payer can verify that the services billed were actually provided, and
A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand and have been provided with a Notice of Privacy Practices effective 4/1/03 that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

The right to review the notice prior to signing this consent.
The right to object to the use of my health information for directory purposes, and
The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations.

I understand that Michael Frampton M.D., P.C. is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the code of Federal Regulations. I further understand that Michael Frampton M.D., P.C.reserves the right to change their notice and practices and will document changes prior to implementation, in accordance with Sections 164,520 of the Code of Federal Regulations. Should Michael Frampton M.D., P.C. change their notice, they will send a copy of any revised notice to the address I have provided (whether U.S. mail or, if I agree, email).

Michael Frampton M.D., P.C.
9120 Connecticut Drive, Suite A
Merrillville, IN 46410

I wish to have the following restrictions to the use of my health information:

I hereby consent to verbal communication to the following spouse, or other relative(s) or person(s) regarding billing, appointments, prescriptions, lab results and treatment plans:

I understand that as part of this organization’s treatment, payment, or healthcare operations, it may be necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. I fully understand and accept / decline the terms of this consent.

Choose One of the Options:

Patient Signature: (Type your name to agree)

Today's Date:

Responsible Person's Signature: (Type your name to agree)

Today's Date:

Relationship to Patient:

Guardian Disclaimer:

Yes, I understand that I will need to provide proof of Guardianship

Power of Attorney Disclaimer:

Yes, I understand that I will need to provide proof of Power of Attorney

If other, describe relationship to patient

Email Address:

Retype Email Address:

New Patient Enrollment Form

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