Forms
A few of the forms used at Full Heart Therapy, LLC are below. Additional forms are sent through the scheduling system after a Free Consultation.
Notice of Privacy Practices
Notice of Privacy Practices informs you of your rights regarding privacy and security as a client. This is based on Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA is United States legislation providing data privacy and security provisions for safeguarding your medical information.
Insurance Questionnaire/Confirmation of Benefits Form
You can use the Insurance Questionnaire/Confirmation of Benefits form to ask your Insurance Provider questions about seeking reimbursement of services with an Out-of-Network Provider. Hopefully, this form assists you in better understanding your insurance policy and benefits, as well as helping you make a more informed decision in choosing to work with me.
No Surprise Billing: Good Faith Estimate and Disclosure Notice Regarding Patient Protections Against Surprise Billing
As of January 1, 2022: State-licensed or certified health care providers must give a Good Faith Estimate of healthcare charges to every new and continuing client who is either uninsured or is not planning to submit a claim to their insurance for the healthcare services they seek. Once you schedule an initial appointment you will receive a letter to review and a form to fill out. You will receive these via the Client Portal (scheduling system).
