Patient Information

I have read and understood the Payment and Office Policies of Integrated Psychiatric Services. I agree to pay for services under the conditions and specifications set forth in this billing policy and acknowledge that I am responsible for payment of all services provided, regardless of insurance coverage.

I acknowledge that I have read and fully understand the Integrated Psychiatric Services HIPAA Policies.

I hereby authorize Integrated Psychiatric Services (IPS) to release and/or obtain information from the records- Psychiatric Evaluation, Medication evaluation, Ongoing Treatment, Insurance Request/Claims.
The information to be released and/or obtained includes all or some of the following:
1. Psychiatric Evaluation, Progress Notes, Course of Treatment, Medication History, Psychosocial History, Hospitalization Course, Discharge Summary
2. Psychological Testing Reports
3. Medical/Surgical Records
4. School Records
5. Lab/Imaging Reports
6. Juvenile Court Records
7. Other social agency reports.
Authorization will remain in effect for: The time necessary to complete my treatment or Court mandate.
I understand that in order to protect confidentiality, my agreement to obtain and/or release information is necessary, and this permission is limited for the purposes and to the person listed above. I also understand that unless otherwise limited by state or federal regulations (such as court mandate) I can cancel this consent at any time, except for action, which has already been taken.

Permission is hereby given for any medical/surgical procedure, X-rays, drug or laboratory test, medication, or exam as may be deemed necessary by the Psychiatrist, Physician Assistant, or Nurse Practitioner. I understand I have the right to see a psychiatrist if I choose and have the right to see a psychiatrist prior to any prescription drug or device order being carried out by an Advanced Practitioner. In the case of an unemancipated minor, the consent below is being given on his or her behalf.

Acknowledgement of Privacy Rights: By signing below, I acknowledge that I am aware of the Integrated Psychiatric Services (IPS) Notice of Privacy Practices and Individual Rights. We may use or share your medical information with personnel involved in your care at IPS. We may disclose your medical information to people outside of the system, such as Health Information Exchanges. IPS Notice of Privacy Practices contains more information about the policies and practices protecting the patient’s privacy. I acknowledge that I have read the above, am giving my consent to the above, and am acknowledging I have been informed of my rights to privacy.