Client Information (Child)

This form is to be completed for our children patients only. Please fill out this form with the best of your knowledge. There are some fields which are required.
Seeking treatment for
Name*
First Last
D.O.B*
MM slash DD slash YYYY
Preferred Pronoun
Child's grade and school
Parent(s) Names*
Relationship*
Visitation schedule
Address
Street Address City State ZIP Code
If separated or divorced please indicate other parent address
- Mother
- Father
Street Address City State ZIP Code

Children/ siblings, name and age

child 1	child 2	child 3

Mother's cell*
Mother's Email*
Employment
Fathers cell*
Father's Email*
Employment
Referred By:*
Times Available
Insurance
Will you be using an insurance co-payment?*
Insurance Carrier*
Insurance Type*
Policy Holder Name*
First Last
Legal Gender*
- Male
- Female
Issuer ID (if available)
Date Of Birth*
MM slash DD slash YYYY
Individual/Member ID #*
Group #*

Please List All Family Members Covered Under This Policy

Click the "+" Icon to add an additional member.

Patient Name	Gender	Date of Birth	Relationship to Policy Holder

Insurance Information
Drop files here or

Max. file size: 256 MB, Max. files: 2.
Please upload a scanned copy of your insurance card (Front + Back) Alternative: Bring me a copy of your insurance card in person or mail (front + back )
Request For Electronic Claim Submission
Insurance Claim Submission Policy
Elena Kaiser Psychotherapy LCPC ATR BC is a member of the Blue Cross Blue Shield of Illinois (BCBS-IL) Participating Provider Organization. If you would like Elena Kaiser Psychotherapy LCPC ATR BC to submit your claims electronically, please review the information below, and return it to Elena Kaiser.*
• Clients are responsible for contacting their insurance companies and understanding their insurance prior to the first session. • Charges for services not covered by insurance, e.g., deductibles, uncovered and ineligible services, and all charges for services provided over the maximum allowable benefit for the year, are the client’s responsibility.
I agree to the privacy policy.
• Clients who change insurance companies or become eligible for Medicare while in therapy at Elena Kaiser Psychotherapy LCPC ATR BC must immediately notify Elena Kaiser. • A change in insurance while in therapy may mean: 1. Clients may no longer be able to collect from insurance if they wish to keep the same therapist, or if they must be reimbursed by insurance, OR 2. Clients may have to refer to a different therapist other than Elena Kaiser*
I agree to the privacy policy.
Policy On Pre-Authorizations
Some BCBS plans may use third-party administrators to pre-authorize their mental health benefits. Please contact BCBS at the beginning of your treatment to determine if pre-authorization is needed prior to treatment.
• Please work directly with Elena Kaiser to make sure that all authorizations are acquired at the appropriate times in order to maximize your benefits. • If services are performed without authorization, all uncovered services or services covered at a lower rater will be the client’s responsibility.*
I agree to the privacy policy.
Policy On 3rd Party Coverage
Some BCBS plans may use third-party administrators to pre-authorize their mental health benefits. Please contact BCBS at the beginning of your treatment to determine if pre-authorization is needed prior to treatment.
• Please be aware that if your mental health benefits are covered through another carrier, such as United Behavioral Health, Magellan, ComPsych, or Value Options, Elena Kaiser Psychotherapy LCPC ATR BC is not considered in network and PPO rates do not apply. • Outsourced coverage cannot be submitted electronically, and you will be expected pay the full fee at the time of service.*
I agree to the privacy policy.
I have reviewed and I understand Elena Kaiser Psychotherapy LCPC ATR BC Insurance Submission Policy and request to have my claims filed electronically with Blue Cross Blue Shield of IL.
Printed Name*
Today's Date*
MM slash DD slash YYYY
Signature*
Medical History
How did you hear about us?
Allergies:
Surgeries:
Medical History
Trauma History - emotional, physical, sexual, medical
Dr. Name
First Last
Phone
Current Therapies (e.g. Mental Health, Speech and Language, Occupational):
Is your child currently undergoing any current therapies (e.g. mental health, speech and language, occupational):*
Name Specialty Phone
Treatment
Treatment Duration
Is your child currently using more than one therapy?
Name: Specialty: Phone:
Treatment Duration:
Treatment
Hospitalization History:
Other Traumatic Events (e.g. death of a loved one, injury, accident, divorce, loss of close teacher, communication difficulties, surgeries, family moves, school changes, etc.):
Personal Reflection
Would you like to add any personal reflections for your child?
Current School Name
Negative Cognitions, Negative Self Beliefs:
Positive Cognitions:
Strengths and Interests
Examples of Imaginative Power:
Sleep Schedule:
Bedtime
How often does your child use the following:
Smart Phone Tablet Computer
Allergies:
Is your child a good or poor eater:
Games your child enjoys:
Goals for Treatment
Consent for Treatment*
Service Agreement/Consent For Treatment
Elena Kaiser is committed to strengthening and healing families from all walks of life through clinical service and education. She offers a wide range of high-quality mental health counseling. Elena Kaiser’s hours are by appointment only. Please be aware that children under 12 cannot be left alone in waiting rooms. If your children are not participating in your session, please make arrangements for their care.
Please check this box for: service agreement/ consent for treatment*
- Check box
TERMS OF AGREEMENT:
I. SERVICES: May include but are not limited to family, couple, individual, and group therapy, school consultation, psychiatric consultation, evaluation, and treatment as well as other diagnostic services as recommended by the clinician. Services may also include the participation of parents/guardians and other significant family members, when appropriate. You or your therapist may suggest other kinds of services (non-direct) outside the scope of normal therapy that would be billable separately such as school visits, phone consultations, writing or reviewing letters, reports, etc. Recommendations for treatment are first discussed with and approved by the client. Treatment length will be evaluated based on progress towards mutually agreed upon goals for therapy. Modalities may or may not include EMDR, hypnotherapy, mindfulness and body-mind psychotherapy, art therapy, play therapy and integration of several as agreed upon.*
I agree to the privacy policy.
II. ELECTRONICALLY MEDIATED PSYCHOTHERAPY: Because of the nature of email, real-time chat phone therapy and video conferencing, I cannot guarantee the privacy of these communications. Therefore, clients acknowledge the potential risk to confidentiality inherent in the use of these technologies. Additionally, at this time insurance companies do not provide coverage for these services and clients are expected to pay the full fee. Before electronically mediated psychotherapy can be initiated Elena Kaiser will conduct an in-person assessment.*
I agree to the privacy policy.
III. FEES & INSURANCE: Clients are expected to pay all fees and co-payments at the time of service. If clients choose to submit bills to insurance, clients are responsible for contacting their insurance companies and understanding their insurance benefits. When possible, charges will be submitted electronically. Charges for services not covered by insurance are the clients’ responsibility. If insurance changes during the course of therapy, clients should notify Elena Kaiser immediately to ensure continued coverage of services.*
I agree to the privacy policy.
IV. APPOINTMENT CANCELLATION POLICY: Charges will apply for appointments canceled or changed with less than 24 hours notice. Extenuating circumstances are considered when appropriate. Insurance benefits do NOT cover cancellation charges.*
I agree to the privacy policy.
CLIENT CONSENT TO TERMS OF AGREEMENT: I (we) understand the SERVICE AGREEMENT with Elena G. Kaiser LCPC ATR BC in accordance with this agreement. A signature is required from the parent(s) or guardian(s) who have legal responsibility for medical decisions for children in treatment, as well as any child 12 years old or older. I (we) understand we have the right to revoke this consent at any time. This revocation must be in writing to Elena Kaiser Psychotherapy. As a guarantor, I am accepting financial responsibility for services received.
Full Legal Name of Guarantor*
First Last
Date Signed*
MM slash DD slash YYYY
Signature*
Is your child above the age of 12?*
Full Legal Name of Child (only if they are 12 or older)
First Last
Date
MM slash DD slash YYYY
Minor's Signature
Elena Kaiser HIPPA Policy
Please use drop down menu to select and read Elena kaiser's HIPPA Policy*
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR CHILD AND FAMILY MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS CAREFULLY. If you have any questions about this notice, please contact Elena Kaiser.

Address: 2530 Crawford ave, suite 305

Evanston, Illinois 60201

Phone: 847-337-2377

Email: elena@elenakaiser.com

INTRODUCTION This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA).

Elena Kaiser PC is committed to treating and using your protected health information responsibly. This Notice of Health Information Privacy Practices describes the personal health information Elena Kaiser PC collects, and how and when its representatives may use or disclose that information. This notice also describes your rights as they relate to your Protected Health Information. This Notice is effective September 1, 2017 and applies to all protected health information as defined by federal regulations.

ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE You will be asked to sign an acknowledgement of receipt of this Notice. Elena Kaiser PC’s intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your speech and language therapy services will in no way be conditioned upon your signed acknowledgement. If you decline to sign the acknowledgement, Elena Kaiser PC will continue to provide treatment, and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.

UNDERSTANDING YOUR HEALTH RECORD/INFORMATION A record of each speech therapy session is made. This record may contain your symptoms, examinations and results, diagnoses, treatment, and a plan for future care or treatment. This information, often called your health or medical record, serves as a:
- Basis for planning your care and treatment,
- Means for communication between the many health professionals who contribute to your care,
- Legal document describing the care you received,
- Means by which you or a third-party payer can verify that services billed were provided,
- A tool in educating health professionals,
- A source of data for medical research,
- A source of information for public health officials charged with improving the health of this state and the nation,
- A source of data for my planning and marketing,
- A tool by which Elena Kaiser PC can continually work to improve the care its representatives provide and the outcomes they achieve.
Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

YOUR HEALTH INFORMATION RIGHTS Although your health record is the physical property of Elena Kaiser PC the information belongs to you. You have the right to:
- Obtain a paper copy of the Notice of Privacy Practices upon request,
- Inspect and obtain a copy of your health record as provided for in 45 CFR 164.524,
- Request and Amend your health record as provided in 45 CR 164.528,
- Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528,
- Request communications of your health information by alternative means or at alternative locations,
- Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522, and,
- Revoke your authorization to use or disclose health information except to the extent that action has already been taken.
Elena Kaiser PC’S RESPONSIBILITIES: Elena Kaiser PC is required to:
- Maintain the privacy of your health information,
- Provide you with this notice as to Elena Kaiser PC legal and privacy practices with respect to information its representatives collect and maintain about you,
- Abide by the terms of this notice,
- Notify you if Elena Kaiser PC is unable to agree to a requested restriction,
- Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative location, and
- Obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted under law.
Elena Kaiser PC reserves the right to change Privacy Information practices and to make the new provisions effective for all protected health information its representatives maintain. Revised notices will be available as requested. Elena Kaiser PC will not use or disclose your health information without your authorization, except as described in this notice. Elena Kaiser PC will also discontinue to use of your health information after it has received written revocation of the authorization according to the procedures included in the authorization.

EXAMPLES OF HOW Elena Kaiser PC MAY USE OR DISCLOSE YOUR HEALTH INFORMATION

For Treatment: Elena Kaiser PC may use your health information to provide you with services. This may include recording information regarding your treatment, the course of action that Elena Kaiser PC will take to treat your issues, and how you respond to these activities.

For Payment: Elena Kaiser PC may use and disclose your health information to others for purpose of receiving payment for treatment and services that you receive. For example, a bill may be sent to you or a third-party payor, such as your insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and the treatment used in the course of treatment.

For Quality Control: Elena Kaiser PC may use your information to assess the treatment provided and outcomes in your and similar cases. This information would then be used to continually improve the quality and effectiveness of the therapeutic services Elena Kaiser PC provides.

Appointments: Elena Kaiser PC may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services and services that may be of interest to you.

Directory: Unless you notify Elena Kaiser PC that you object, Elena Kaiser PC may use your name if you have been transported to a hospital or other facility to check on your status.

Notification or Communication with Family Members: Elena Kaiser PC therapists, using their best judgment, may use or disclose information to notify or assist in notifying family relatives, personal representatives, close personal friends, or other people you identify; information relevant to that person's involvement in your care or payment information related to your care.

Research: Elena Kaiser PC may disclose information to researchers when their research has been approved by an institutional review board (IRB) that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Public Health: Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, disability, or for other health oversight activities.

Required by Law: Elena Kaiser PC may use and disclose information about you as required by law. For example, Elena Kaiser PC may disclose information about you for the following purposes:
- For judicial and administrative proceedings pursuant to legal authority,
- To report information related to victims of abuse, neglect, or domestic violence, and
- To assist law enforcement officials in their law enforcement duties.
Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority, or attorney, provided that a workforce member or business associate believes in good faith that Elena Kaiser PC has engaged in unlawful conduct or has otherwise violated professional or clinical standards, and is potentially endangering one or more clients, workers, or the public.

Health and Safety: Your health information may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.

Government Functions: Specialized government functions such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of your health information.

OBTAINING AND STORAGE OF INFORMATION Your information will be obtained from medical facilities, agencies, and other persons involved with the health care of your child and family only with your written consent. Your signature is required in order for healthcare information to be obtained from outside sources.

Medical information may be delivered through U.S. mail or through facsimile services. All documentation delivered via U. S. mail will only be opened by Elena Kaiser PC. Facsimiles arrive in a private location and are also only obtained by Elena Kaiser PC. Once these documents arrive they are placed into your child’s secured file. Other professionals may also request contact via telephone. Minimal information will be given via cellular communication in public locations. Should another professional wish to complete such a call, a request will be made to reschedule for another time or Elena Kaiser PC will move to a location where your privacy can be assured.

ELECTRONIC DATA (via TheraNest practice management)

SECURITY TECHNOLOGY AND PRACTICES Your sensitive data is hosted in a Tier 1 secure hosting provider specializing in helping healthcare organizations achieve and maintain HIPAA and HITRUST security requirements:
- Web pages and APIs are secured with 128-bit Secure Socket Layer encryption.
- Our cloud infrastructure uses multi-factor authentication.
- We use advanced key management and transparent data encryption.
- Application level monitoring and intrusion protection.
- HIPAA compliant encryption.
- HIPAA compliant hosting architecture on enterprise level hardware.
- HIPAA compliant system architecture with separate web and database environment.
- Application and Database server isolation.
- Firewall management.
- Log retention with detailed audit trail.
- Managed and secure backup and disaster recovery.
- Managed patching, version control, and security updates.
- Credit card transactions processed using secure encryption on a PCI compliant network.
Once medical information has been obtained, it will be placed in a confidential folder and / stored on Elena Kaiser PC’s secure software system. No one other than Elena Kaiser PC will have access to these files without your written and signed consent.

After six years of inactive status, your hard copy stored medical information will be destroyed via shredding. The shredded information will then be discarded.

For more information, to discuss a problem, or if you have questions and would like additional information, you can contact Elena Kaiser PC:

Elena Kaiser PC

Address: 2530 Crawford ave, suite 305

Evanston, Illinois 60201

Phone: : 847-337-2377

Email: elena@elenakaiser.com

If you believe that your privacy rights have been violated, you can discuss the situation with Elena Kaiser PC, or you can file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either Elena Kaiser PC or the Office for Civil Rights. The address for the OCR is listed below:

Office for Civil Rights-U.S. Department of Health and Human Services

200 Independence Ave.,
1. W. Room 509, HHH Building
Washington, D.C. 20201

866-OCR-PRIV (866-627-7748) or 886-788-4989 TTY

ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE Elena Kaiser PC is concerned about the privacy of your health care information. Elena Kaiser PC intent is to make you aware of the possible use and disclosures of your protected health information and privacy rights. The delivery of your therapy services is in no way conditioned upon your signed acknowledgment. If you decline to provide a signed acknowledgment, Elena Kaiser PC will continue to provide treatment, and use and disclose your protected health information for treatment, payment, and health care operations as necessary.
Consent*
I agree to the HIPPA policy.
Credit Card Authorization
Name on Credit Card
First Last
Guarantor's Date of Birth
MM slash DD slash YYYY
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Please check ONE of the following options below:
- First Choice - Enter my credit card into a secure credit card payment gateway for future use.
- Second Choice - One-Time Charge (CVS Required)
- Third Choice - Replace old credit card on file
Consent
• I hereby authorize Elena G. Kaiser LCPC ATR BC to allow TherapyPartner.com a secure, data compliant intermediary credit card payment gateway to keep my account information on file for payment and to initiate debit or charge entries.
Charge my credit card for this one time only for:*
Date of service*
MM slash DD slash YYYY
Signature name
Name
First Last
Credit Card
- Visa
- Master
- Discover
CVV number*
Card number*
Expiration date. Month and Year*
CAPTCHA

Client Information (Child)

This form is to be completed for our children patients only. Please fill out this form with the best of your knowledge. There are some fields which are required.

Insurance

Request For Electronic Claim Submission

Policy On Pre-Authorizations

Policy On 3rd Party Coverage

Medical History

Current Therapies (e.g. Mental Health, Speech and Language, Occupational):

Personal Reflection

Service Agreement/Consent For Treatment

Elena Kaiser HIPPA Policy

Credit Card Authorization

Call Us: 847-337-2377

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