NEW PATIENT FORM

Remember 24 hour notice is needed for cancellation of appointment or you will be charged the $50 missed session fee.

Call me if I can be of assistance to you.

Best Wishes,

Patrick Martin, MA, MFT, Operation Director

  • phone conversations or Video Skype conversations
  • e-mail (Free for short messages)
  • reviewing educational records, documents and testing
  • research
  • writing/reviewing letters

PLEASE PRINT OUT ONLY IF YOU DID NOT GET ONLINE VERSION WORKING.

OPTIONAL FORMS


Insurance is great but not always great for the providers as we have difficult ever receiving money for the services provided. This is some helpful information for you to understand what we go through. Although Family Counseling San Diego (AKA FamilyCounselingSanDiego.com) or Director, W Patrick Martin, MA, LMFT whom is on multiple insurance panels that is not an assurance of your insurance paying or that we know what your EOB (Explanation of Benefits) includes coverage with your insurance that is your responsibility. If we state we will take your insurance for example, you tell us that you have a PPO that does not insure payment to us or yourself. We do take all PPOs but recently found an exclusion with Anthem and no longer will take any Anthem insurance. We sometimes deal directly with insurance providers, we are happy to provide you with some helpful hints regarding your insurance but have spent hours attempting to come to an agreement with some insurance carriers but they refuse to provide direct phone numbers or ways to address billing issues that arise at times. With Anthem specifically we have sent there Behavioral Health Provider email which is all they provide us as a way to contact them without any response after there costumer service representative assured us they would response within 2-3 business days which we have attempted multiple times for Anthem which is why we refuse to deal with them further. Please complain to them to allow your provider to be on there panels as there is few people whom has the specialized trained staff that we have.We are a direct payment practice: this means that you pay us for each visit at the time of service, and we provide you with an itemized statement that you may choose to submit to your insurance provider. This statement is what most insurance providers request in order to respond to your claim. It is important that you attach it to your insurance claim form and mail it to your provider for reimbursement.If we try to help you with your insurance provider; hence, we bill your insurance and take just the co-payment, we strongly recommend that you clarify ahead of time what type of coverage with your insurance you have for mental health services (Psychiatry, Medication Management, Psychotherapy, and Group Therapy). Coverage can change; you will want to know this ahead of time and YOU ARE ALWAYS RESPONSIBLE TO KNOW YOUR (Explanation of Benefits). Not ours as there is 1000s of different insurance plans.

  • 1. Out of Network benefits: we are considered an Out of Network (OON) provider for some insurances. Ask about the deductible, percentage of coverage for each visit, maximum number of visits covered yearly and lifetime for OON providers. Does your insurance year start in January: not all do.
  • 2. InNetwork benefits: FamilyCounselingSanDiego.com with Walter Patrick Martin, MA, LMFT has joined Tricare West, UHC Military, Optum Health Military, Medi-Cal San Diego, Aenta, Beacon, Humana, Bluecross of California.
  • 3. Is PreAuthorization or PreCertification required in order to start services? If so, who calls to request it? If Preauthorization/Precertification is required, and you do not comply, you are doing so at the risk of losing all reimbursement for treatment. So please call your insurance requesting PreAuthorization if you are unsure.
  • 4. R&C: This is the “reasonable and customary” price of each service. Insurance providers determine the price for each treatment service according to their own system. Different insurance providers pay different R&Cs. Keep in mind that the R&C amount your provider has set may not necessarily match our fee schedule. If you do receive reimbursement from your insurance provider, realize that you will be receiving benefits based on the particular percentage of their R&C your provider sets, not ours.
  • 5. Ask for the specific payer code # and address to send your claims as some insurance companies have multiple address and multiple payer code numbers. Is a special form needed to complete claims? How long will you be waiting for reimbursement? We suggest keeping a separate binder for all of your insurance provider documents.We hope this is helpful.   Janet Phillips, LCSW      Walter Pat Martin, LMFT

IF YOU ARE ON AN AGREED PAYMENT PLAN PLEASE CLICK BELOW AND PAY THROUGH PAYPAL.

Payment Options



 

HIPPA PRIVACY NOTICE -NOTICE OF PRIVACY PRACTICES

MY PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at Family Counseling San Diego. 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 in which we may use and share your protected health information (“PHI”). It also describes your rights and certain actions we must take when using or sharing your PHI with other people or organizations. We are required by law to: make sure that PHI linked to you is kept private and confidential (with some exceptions as listed below); give you this notice about our responsibilities and privacy practices about your PHI; and follow the terms of the notice that is currently in effect. Except as outlined below, we will not use or share your PHI unless you have signed an authorization form that gives us permission to do so. You have the right to cancel the permission by telling us in writing, except if we have already used or shared your PHI when you first gave us permission.
HOW WE MAY USE AND SHARE PROTECTED HEALTH INFORMATION
The following sections describe different ways that we use and share (disclose) your PHI. We will describe each category of uses and disclosures, and give some examples. The law limits how we can use and disclose some PHI related to treatment of drug and alcohol abuse, HIV infection, and mental illness. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the following categories.
For Treatment
We may use your PHI to provide you with treatment or services. We may share it with doctors, nurses, technologists, medical students, or other healthcare personnel who are involved in your care, with your signed permission.
For Payment
We may use and share your PHI to bill for the services we provide to you and to collect payment for the services billed, from you, your insurance company or a third party. We may also share PHI with another provider so that provider can bill and collect for services you received. For example, we may share your PHI with your health plan so that it can list services received by you on your itemized bill. We may also tell your health plan about a treatment you need so we can care for you, or ask if your plan will pay us for the treatment.

Appointment Reminders
We will use and share PHI to schedule an appointment, or to remind you that you have an appointment for treatment.
Treatment Alternatives. We will use and share PHI to tell you about possible treatment options that may interest you.
Health-Related Products and Services. We will use and share PHI to tell you about our health-related products or services that may interest you. Individuals involved in your care or payment for your care. We may share your PHI with a family member, friend, personal representative, or anyone else you want to be involved in your care. With signed consent. We may share your PHI with anyone who helps pay for your care, with your signed consent.

As Required By Law
We will use and share your PHI when required to do so by federal, state or local law. To Avert a Serious Threat to Health or Safety. We may use and share your PHI when necessary to prevent or lessen a serious threat to your health and safety, or to that of others. However, we will share your PHI only with a responsible person who is able to help prevent the threat.
Military Service and Veterans
If you are or have been a member of the Armed Forces, we will not share your PHI unless federal judge requests the information which would only be in extreme cases such as murder and death. We may also release PHI about foreign military personnel to the appropriate military authorities as authorized or required by law through a court order only.
Workers’ Compensation
We may share your PHI as permitted by law for workers’ compensation or similar programs when necessary to provide you with treatment, services, or benefits for work-related injuries or illness.
Public Health Risks
We may use and share your PHI for public health purposes. In general, these activities include, but are not limited the following: to prevent or control disease (such as cancer or tuberculosis), injury or disability;
to report births and deaths; to report the abuse or neglect of children, elders and dependent adults; to report reactions to medications, or problems with healthcare products; to notify patients of recalls, repairs, or replacement of products they may be using; to notify a person who may have been exposed to a disease or may be at risk for getting or spreading a disease or condition; to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will share your PHI only if you agree or when it is required or authorized by law.
Health Oversight Activities
We may use and share your PHI with a healthcare oversight agency as authorized or required by law. These oversight activities include, for example: audits, investigations, inspections, accreditation and licensure surveys. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes
We may share your PHI in response to a court or administrative order, a subpoena, discovery request, warrant, summons, or other lawful process. We will do so only after we make efforts to tell you about the request, (which may include a written notice to you) or to obtain an order protecting the information requested.
Law Enforcement
We may use and disclose PHI if asked to do so by a law enforcement official: in compliance with a court order, subpoena, warrant, summons, grand jury subpoena or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about a victim or a crime, if, under some limited circumstances, we are unable to obtain the permission directly from the victim of a crime; about a death we believe may be the result of criminal conduct;
about criminal conduct in any of our facilities; and in emergency circumstances to report: a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors
We may use and share your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release your PHI to funeral directors when necessary for them to carry out their duties.
National Security and Intelligence Activities
We may use and share your PHI to federal officials for intelligence, counterintelligence, and other national security activities as authorized or required by law.
Protective Services for the President and Other Persons
As authorized or required by law, we may use and share your PHI to authorized federal officials so they can protect the President, the President’s family, other designated persons or foreign heads of state, or conduct special investigations.
Inmates
If you are in a correctional institution or under the custody of law enforcement officials, we may use and share your PHI with the correctional institution or law enforcement officials if they tell us that it is necessary: (1) to provide the healthcare services you need, (2) to protect your health and safety or that of others, or (3) for the safety and security of the correctional institution.
OTHER USES OF PROTECTED HEALTH INFORMATION
Other uses and disclosures of PHI not covered by this notice, or by the laws that apply to us will be made only with your written permission. If you allow us to use or share your PHI, you may cancel that permission, in writing, at any time. If you cancel your permission, we will stop any further use or disclosure of your PHI for the purposes covered by your written permission. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required by law to keep records of the services or treatment we provided to you.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
You have the following rights regarding your PHI that we maintain in our facilities.
Right to Inspect and Copy
Except for information related to treatment of mental illness, or information gathered in a civil, criminal or administrative action or proceeding, or some PHI subject to the Clinical Laboratory Improvements Amendments of 1988, you have the right to ask to inspect and copy your PHI. To inspect and copy your PHI, you must send a specific, detailed request in writing to the Custodian of Medical Records addressed as follows:
Patrick Martin, MA, LMFT, PO BOX 487, BONSALL, CA 92003
You may ask for a review if we deny a request to inspect and copy except: 1) in circumstances listed above; 2) you are an inmate and the copies would jeopardize your health safety, security, custody, or rehabilitation or that of others; 3) if the PHI is obtained as part of a research study, your right to access your PHI is suspended during the research; 4) if the PHI is controlled by the Privacy Act and access is not permitted by law; or 5) if the PHI was obtained from someone other than a healthcare provider under a promise of confidentiality and access to the PHI would reveal who that person is.
You must ask for a review in writing addressed as follows:
Patrick Martin, MA, LMFT, PO BOX 487, BONSALL, CA 92003

A mental health care provider other than the person who denied your request will review the denial. We will provide or deny access in accordance with the decision of the provider who reviewed the denial.
Right to Amend
If you feel that your PHI in our custody is incorrect or incomplete, you may ask us to correct or amend the PHI. You have the right to request a change for as long as we keep your PHI. To ask for a change, you must write to our Custodian of Medical Records with a reason that supports your request at the following address: Patrick Martin, MA, LMFT, PO BOX 487, BONSALL, CA 92003. We will not change your PHI unless you write us, or do not include a reason to support your request. In addition, we may deny your request if you ask us to change information that: was not created by us; is not part of the information kept by or for us; is not part of the information which you are permitted by law to inspect and copy; or is accurate and complete. If we deny your request to change your PHI, you have the right to submit a written correction about any item or statement in your medical record you believe is incomplete or incorrect. The correction cannot exceed 250 words for each item you feel is incorrect or incomplete.

Right to an Accounting of Disclosures
You have the right to request a list that shows how we use or share your PHI other than disclosures made: 1) to you or authorized by you; 2) for national security or intelligence purposes; 3) to correctional institutions or law enforcement; 4) as part of a limited data set as permitted by law; or 5) for treatment, payment and healthcare operations (as described above). To request this list, you must write to our Custodian of Medical Records at the following address: Patrick Martin, MA, LMFT, PO BOX 487, BONSALL, CA 92003. Your request must state a time period, which cannot be more than six years, and cannot include dates before April 14, 2003. Your request should describe the type of list you would like (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions
You have the right to ask that we limit how we use or share your PHI for treatment, payment or healthcare operations. You also have the right to ask us to limit what we share about you to someone who is involved in your care or in the payment for your care, such as a family member or friend. For example, you can tell us not to use or share information about a surgery that you had done at SCVMC, or about a treatment you received at one of our other facilities. We are not required to agree to your request. If we do agree, we will comply with your request, unless the information is needed to provide emergency treatment to you. To request restrictions, you must write to our Custodian of Medical Records at the following address:
Patrick Martin, MA, LMFT
PO BOX 487, BONSALL, CA 92003
In your request, you must tell us: (1) what information you do not want us to use or share; (2) whether you want to limit our use, sharing of your PHI or both; and (3) to whom you want the limits to apply, for example, sharing with your spouse or a family member.
Right to Request Confidential Communications
You have the right to ask that we communicate with you about your PHI in a certain way or at a certain location. For example, you can ask that we contact you only at work or by U.S. mail. To request confidential communications, you must write to:
Patrick Martin, MA, LMFT
PO BOX 487, BONSALL, CA 92003
We will not ask you the reason for your request, and we will try to accommodate all reasonable requests. You must tell us how or where you want to be contacted.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time in person, or by writing to:
Patrick Martin, MA, LMFT
PO BOX 487, BONSALL, CA 92003

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