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Online IOP(Intensive Outpatient Programs) - Intake Form
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Sex
Male/Female/Other
Date of Birth

MonthDayYear
Date
Referral Source (If applicable)
How did you hear about our IOP?*
Best time to call
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Relationship
Please enter a valid phone number.
In the past week,have you had thoughts of harming yourself or ending your life?

NoYes,but I have no intent to actYes, and I have some intent to actYes, and I have a plan
FOR MEDICAID RECIPIENTS ONLY
Name of Insurance Company
Member ID Number
Medicaid ID Number
PLEASE PROVIDE THE FOLLOWING INFORMATION ONLY IF YOU HAVE COMMERCIAL INSURANCE:
Do you have insurance?

YesNo
Insurance Front Side

Cancelof
Insurance Back Side

Cancelof
Additional Insurance Information

YesNo
Name of Policy Holder
DOB of Policy Holder

MonthDayYear
Date
Relationship to Client
Place of Employment
Name of Insurance Company
Member ID
Annual Deductible Amount
Group Number
Copay Amount
Is there anything you would like to share that would be helpful to the person reaching out to further discuss this with you?

Authorizations:
Release of Information to Insurance Company (Please check that you understand):

I hereby authorize the release to my insurance company of any information required in the course of my examination or treatment. This information may be released now or in the future.I hereby assign to GetWell Health System (GWHS) any and all rights, title, and interest that I have in any insurance proceeds or benefits payable to me or on my behalf for services rendered to me by GWHS, whether services are considered in-or out-of-network.I authorize and direct my insurance carrier and/or health care plan to make payment of any and all such amounts directly to GWHS, rather than myself or any other insured.I understand that I am financially responsible to GWHS for all charges, including those not paid by insurers or health care plans for services not authorized as specified ified in my benefit package, incurred by me or in my behalf.
Authorization for Medical Treatment (Please check that you understand):

I hereby authorize the physicians, nursing staff, and allied health professional staff (assisted by the employees of GetWell Health System to provide medical treatment to me or the above named patient.I agree to diagnostic tests and procedures, including x-rays, CT, and the administration/injection of pharmaceutical products and medication in addition to the drawing of blood.I understand and authorize the administration of pharmaceutical agents and medications.I acknowledge that no guarantees or assurances have been made to me concerning the results or findings intended from treatment or examination at GetWell Health System
Power of Attorney

I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect the care I receive from the provider, my eligibility for benefits, or enrollment, payment, or coverage of these services.
I HAVE READ, UNDERSTOOD, AND AGREE TO ALL OF THE ABOVE INFO.
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Printed Name of Legal Representative

First NameLast Name
Signature of Legal Representative

Clear
Date

MonthDayYear
Date
Please verify that you are human*

HIPAA Release of Information Authorization Form

GetWell Health System(GWHS)
I hereby authorize GWHS and its affiliates, employees, and agents to release information to:

SpouseFamilyOtherInformation is NOT to be released to anyone.
My or my legal dependents person health information is maintained by GWHS (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided and which identifies me or my legal dependents name, address, social security numbers, and member ID number) except the following information:
For legal proceedings, law enforcement, abuse, neglect, or public health safety or for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that nay personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person or organization and may no longer be protected by applicable federal and state privacy laws; this authorization is valid from the date of my or my representative’s signature below. I understand I have the right to revoke this authorization by providing written notice. However, this authorization may not be revoked if NCMG, its employees, or agents have taken action on the authorization prior to receiving my written notice. I also understand I have a right to have a copy of this authorization.
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date

Authorization for Release of Information
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
I authorize GetWell Health System to disclose my medical records to:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
I authorized North Clark Medical Group to obtain my medical records from:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
I understand that I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released prior to the written revocation. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to consent under my policy. Unless otherwise revoked, this authorization will expire on the below date. If I fail to provide an expiration date, this authorization will expire in 60 days from date of signature.
For legal proceedings, law enforcement, abuse, neglect, or public health safety or for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that nay personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person or organization and may no longer be protected by applicable federal and state privacy laws; this authorization is valid from the date of my or my representative’s signature below. I understand I have the right to revoke this authorization by providing written notice. However, this authorization may not be revoked if NCMG, its employees, or agents have taken action on the authorization prior to receiving my written notice. I also understand I have a right to have a copy of this authorization.
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Witness name

First NameLast Name
Witness Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

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DISCLAIMER: Providers within the GetWell Health System network are independent contractors, with limited exception, who are not employees of Get Well Health System. Independent contractors are responsible for their own work hours, liability coverage, and patient treatment plans.

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Online IOP(Intensive Outpatient Programs) - Intake Form

FOR MEDICAID RECIPIENTS ONLY

PLEASE PROVIDE THE FOLLOWING INFORMATION ONLY IF YOU HAVE COMMERCIAL INSURANCE:

Authorizations:

Power of Attorney

HIPAA Release of Information Authorization Form

Authorization for Release of Information

I authorize GetWell Health System to disclose my medical records to:

I authorized North Clark Medical Group to obtain my medical records from:

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