Internet Addiction Recovery Program APPLICATION ... - HEAL

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Internet Addiction Recovery Program ACKNOWLEDGMENT OF RECEIPT of the Notice of Privacy Practices I acknowledge that I have received or been offered the Notice of Privacy Practices of the reSTART Internet Addiction Recovery Program. I understand that the Notice describes the uses and disclosures of my protected health information by the Covered Entities and informs me of my rights with respect to my protected health information. _____________________________________________________________________ Name of Participant _________________________________ Medical Record Number _________________________________ Date of Birth _____________________________________________________________________ Signature of Participant or Personal Representative _____________________________________________________________________ Printed Name of Participant or Personal Representative _____________________________________________________________________ Date If Personal Representative, indicate relationship: _____________________________________________________________________ Declinations ______ ______ The Individual declined to accept a copy of the Notice of Privacy Practices. The Individual received a copy of the Notice of Privacy Practices but declined to sign an Acknowledgment of Receipt. ___________________________________ Signature of reSTART Representative _________________________________ Name of reSTART Representative Page | 10 reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189 restart@netaddictionrecovery.com | www.netaddictionrecovery.com
Internet Addiction Recovery Program MEDICAL INSURANCE INFORMATION ID NUMBER – Copy from your health insurance identification card GROUP NUMBER: IDENTIFCATION NUMBER: PATIENT INFORMATION PARTICIPANTS FULL LEGAL NAME (Last, First, Middle) Sex Male Female SOCIAL SECURITY NUMBER (Optional) / / PATIENT IS: Member Spouse Child Other. Please explain relationship: IF CLAIM IS FOR CHILD 19 OR OLDER‐IS CHILD: A full‐time student Yes No Disabled Yes No DATE OF BIRTH Month Day Year | | PAYEE: MAKE PAYMENT TO THE PROVIDER (HOSPITAL, DOCTOR ETC.), OR MAKE PAYMENT OT MEMBER, THE PROVIDER HAS BEEN PAID MEMBER INFORMATION MEMBERS FULL LEGAL NAME (Last, First, Middle) CURRENT ADDRESS: IF COVERAGE IS THRU YOUR EMPLOYER, PROVIDE Group (Employer name) Sex Male Female SOCIAL SECURITY NUMBER (Optional) / / DATE OF BIRTH Month Day Year | | HOME PHONE: (____) WORK PHONE: (____) OTHER INSURANCE INFORMATION Are there OTHER medical benefits available to you, your spouse, or your dependents form OTHER Group Insurance, including OTHER employers, Labor or Professional Organizations, schools Yes No POLICY HOLDER NAME: POLICY HOLDER IS: Member Spouse Child OTHER, please explain relationship INSURANCE CARRIER NAME: POLICY NUMBER: EFFECTIVE DATE: SOCIAL SECURITY NUMBER (Optional) / / ADDRESS: PHONE NUMBER: (____) RELEASE OF INFORMATION: I certify that the above information is correct to the best of my knowledge. I understand that use or disclosure of individually identifiable health information, whether furnished by me or obtained from other sources such as medical providers, shall be in accordance with federal privacy regulations under HIPAA (Health Insurance Portability and Accountability Act of 1996). A copy of the front and back of the medical insurance card is attached to this application. Sign HERE ____________________________________________________________________ Date ______________________________ Signature of Member Page | 11 reSTART Internet Addiction Recovery Program | 1001 ‐ 290 th Ave SE . Fall City, WA 98024‐7403 | 425.417.1715 | fax 425.222.7189 restart@netaddictionrecovery.com | www.netaddictionrecovery.com
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Internet Addiction Recovery Program APPLICATION ... - HEAL

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