FDF
Application-for-Services-Fillable(1).pdf
Application for Services – 04-2020
1
For Office Use Only
Client Case Number: __________________________
Date Received: __________________________
APPLICATION FOR SERVICES
This application is a part of your C4MH record, and the information provided will be treated as confidential.
This information is required
in order for us to provide you services and bill you and/or your insurance company. Please complete the questions as thoroughly as
possible. The C4MH provides services and benefits to its clients without regard to race, color, religion, gender, national origin, age,
handicap, or economic status.
PLEASE COMPLETE THIS APPLICATION SPECIFIC TO THE PERSON SEEKING SERVICES
Name:
Date of Birth:
Age:
(First)
(Mi)
(Last)
Gender:
Male
Female
Transgender
Other: __________________________
Social Security #:
_____________________________
Maiden/Previous Names Used:
_______________________________________________________________________________________
Address:
_________________________________________________________________________________________________________
(Street or P O Box)
(City)
(State)
(Zip Code)
Home #:
____________________________
Work #:
______________________________
Cell #: _________________________________
Other/Message Phone #: _________________________________
Email Address:
_____________________________________________
_______
I consent to be contacted by C4MH via any of the above listed phone number(s) and/or email address(es).
Legal Status:
Voluntary
Court Order
Civil Involuntary
Criminal Involuntary
Unknown
Probation and/or Parole:
No
Yes
Legal Custody:
Self
Parent/Grandparent
Guardian
Dept of Family Services
Dept of Corrections/Juvenile Justice
Bureau of Indian Affairs/Tribal Court
Other Family
Other, please specify: _______________________________________
Complete only if applicant is under the age of 18 OR if the client has a Legal Guardian:
Parent/Guardian Name: ______________________________________________________
Home #: _______________________________
Address, if different than above: _______________________________________________
Cell #:
________________________________
Relationship/Agency: ________________________________________________________
Work #: _______________________________
Appointment Reminders:
Okay to leave a voice message?
Yes
No
Okay to send a text reminder?
Yes
No
Appointment reminder calls/texts may be made to (person): _______________________________________________________________
Relation: ________________________
Phone #: _____________________________
SOURCE OF REFERRAL
Reason for seeking services: __________________________________________________________________________________________
__________________________________________________________________________________________
Referred by: _______________________________________________________________________________________________________
CONTACT INFORMATION:
IN CASE OF AN EMERGENCY
In case of an emergency and/or scheduling changes, I give consent for the C4MH to contact:
Name:
_____________________________________________________________________
Relation: _____________________________
(First)
(Mi)
(Last )
Address:
_________________________________________________________________________________________________________
(Street or P O Box)
(City)
(State)
(Zip Code)
Home #:
____________________________
Work #:
______________________________
Cell #: _________________________________
Application for Services – 04-2020
2
DEMOGRAPHIC INFORMATION
Race/Ethnicity:
Caucasian
Asian
American Indian,
Alaskan Native
African American
Native Hawaiian,
Other Pacific
Hispanic/Latino
Unknown
More than one
race
Marital Status:
Married
Divorced
Widowed
Separated
Single,
Never Married
Veteran
Status:
Yes
No
Employment Status:
Full-time
Part-time
Retired
Disabled
Student
Homemaker
Supported/Sheltered Employment
Unemployed, but desiring work
No interest in work
Other:
Education Status:
No formal education
Adult Education (GED)
Vocational School
College part-time
College full-time
Home School
Public School K-12
Private School
Other:
Last grade completed: ________
Living Arrangements:
Homeless:
Yes
No
Transient/Hotel
Mission/Shelter
Independently Alone
Independently with Others
Living with Others (in their care)
Supported Independent Living
Mental Health Group Home
Non-MH Group Home
Personal Care Home
Nursing Home
Jail/Pre-Release
Hospitalization (Medical)
Hospitalization (Psychiatric)
Foster Care
Therapeutic Foster Care
Other:
FAMILY HOUSEHOLD INFORMATION
Number of dependents (for whom you have legal responsibility—including client): __________
NAME OF HOUSEHOLD MEMBER
(Include Middle Initial)
RELATIONSHIP
(To Head of Household)
DATE OF BIRTH
(MM/DD/YYYY)
EMPLOYER/SCHOOL
1
2
3
4
5
6
7
DEPENDENTS LIVING ELSEWHERE
(Include Middle Initial)
RELATIONSHIP
(To Head of Household)
DATE OF BIRTH
(MM/DD/YYYY)
EMPLOYER/SCHOOL
8
9
10
11
FAMILY INCOME
List all gross monthly income and benefits you, your spouse, dependents, or other family members receive from any source
(including employment, Social Security, SSI, SSDI, Pensions, VA, Child Support, BIA, etc...).
HH MBR # means Household Member Number from above.
HH MBR #
EMPLOYMENT/WAGES
SOCIAL SECURITY /PENSIONS
PUBLIC ASSISTANCE
OTHER INCOME
TOTALS
$
$
$
$
Add totals from (A) through (D) above for Total Family Income
$
Family stated monthly income is $ ________________ but does not have or will not bring in any documentation verification.
ZERO INCOME:
Check this box
if your total household income is
ZERO:
Application for Services – 04-2020
3
INSURANCE INFORMATION
Do you have Medicaid?
Yes
No
ID#:
Effective Date:
Do you have Medicare?
Yes
No
ID#:
Effective Date:
Do you have private insurance?
Yes
No
ID#:
Effective Date:
Insurance Company Name:
**Please bring the appropriate insurance card(s) with you when returning this packet.**
A.
PERSON RESPONSIBLE FOR PAYMENT:
Self
Spouse
Parent/Guardian
Name:
____________________________________________________________________________________________________________________
Cell #:
Home #
Work #:
Address:
(Street or P O Box)
(City)
(State)
(Zip Code)
Sponsor Name, if Military:
Branch of Military Service:
Rank:
Marital Status:
Single
Married
Other
B.
Employer: __________________________________________
Address: _____________________________________________________________
Contact Person: _____________________________________
Phone #: _____________________________________________________________
PRIMARY HEALTH INSURANCE INFORMATION:
Insured / Policyholder’s Name:
Insured’s SSN:
_______________________________
Insured’s Date of Birth: _______________________
Address:
(Street or PO Box)
(City)
(State)
(Zip Code)
Insurance
Company:
________________________________________________________________________________________________________
Address:
(Street or P O Box)
(City)
(State)
(Zip Code)
Group / Policy #:
______________________________________________
ID#: _______________________________________________________
Client’s Relationship to Insured:
Self
Spouse
Child
Other
C.
ADDITIONAL HEALTH INSURANCE INFORMATION: (
if applicable)
Insured / Policyholder’s Name:
_____________________________________________________________________________________________
Insured’s SSN: _______________________________
Insured’s Date of Birth: ________________________
Address:
________________________________________________________________________________________________________________
(Street or PO Box)
(City)
(State)
(Zip Code)
Insurance Company: _______________________________________________________________________________________________________
Address: ________________________________________________________________________________________________________________
(Street or PO Box)
(City)
(State)
(Zip Code)
Group / Policy #: ______________________________________________
ID#: ______________________________________________________
Client’s Relationship to Insured:
Self
Spouse
Child
Other
D.
Social Security Designation:
(SELECT ONE)
SSI due to Mental Illness
SSI not due to Mental Illness
SSDI due to Mental Illness
SSDI not due to Mental Illness
Does not apply
Application for Services – 04-2020
4
COST OF CARE PAYMENT AGREEMENT
I hereby give authority to the C4MH to furnish all information in which the Social Security Administration, Veteran’s
Administration, my insurance provider, its intermediaries or carriers may request and need in connection with my mental
health condition; at the same time, I give authority to the insurance company to make payable to the C4MH any benefits
which may be due to me under this policy as a result of my mental health condition.
I understand that the C4MH does not accept responsibility for collection of my insurance benefits or negotiating the
settlement of a disputed claim.
I am responsible for payment of all C4MH charges regardless of anticipated insurance
coverage, unless pre-arranged through my employer or a third-party payee.
I understand the C4MH’s policy is to bill my primary insurance carrier for covered services before billing me for the balance
due. In fact, before billing Medicaid or HELP, as a final payer, my primary insurance carrier must be billed. If there is another
agency responsible for payment of my services, I will ensure that information is given at the time of application.
If it is determined I do not qualify for the above services, and/or there is a balance due after my insurance carrier has been
billed for covered services, I will be billed the C4MH’s regular, full-fee rate for services.
I may qualify for the sliding fee scale
which is based on the total family income and the number of individuals in the household, with a personal fee rate determined
when I provide the proof of income documentation.
Other assistance may be offered based on my individual case, such as
maximum amount billed for services and/or financial plan based on what I can afford to pay monthly on my SELF-pay balance. I
will receive a monthly billing statement indicating my balance due and if I am unable to make full payment, I will contact the
C4MH’s billing department at (406)771-8648.
No one will be denied access to services due to inability to pay. There is a
discount/sliding fee schedule available.
I understand that any unpaid charges may be turned over to collections.
I permit a copy of this authorization to be used in place of the original, and request payment of medical benefits to the C4MH.
_____________________________
Please initial for acknowledgement
INFORMED CONSENT TO MENTAL HEALTH TREATMENT
I understand that I may receive services from a variety of C4MH employees in order to meet my specific mental health needs.
I also understand that their participation in my care will be within the scope of their respective professional education,
training, experience, and licensure/certification.
I understand that with my consent, my treatment may change based on my
needs and preferences as well as following the guidelines of the Mental Health Administrative Rules of Montana.
I understand that the practice of mental health treatment is not an exact science and that no guarantees have been or can be
made about the likelihood of success or outcome of any treatment.
I understand there are risks and benefits in mental health
treatment and am agreeing to treatment, including mental health assessment, screenings, and an individual treatment plan.
I understand that my mental health information will only be shared as appropriate under HIPAA Privacy and Confidentiality
Laws and Regulations 42 CFR Part 2. I understand there are allowable circumstances under HIPAA covering treatment,
operations, and payment in which a signed consent release is not required.
I also understand information may be released in
an emergency, as subpoenaed by a court of law or as required by law for mandatory reporting of abuse and neglect.
I hereby voluntarily consent to the treatment provided by the C4MH and its employees or designees. I authorize the services
deemed necessary or advisable by my providers to address my needs.
I understand that if this application is being completed on behalf of another individual (i.e. – a minor or client with a legal
guardian), I am voluntarily consenting to mental health treatment on their behalf as stated above.
_____________________________
Please initial for acknowledgement
Application for Services – 04-2020
5
CLIENT AGREEMENT
SERVICES POLICY.
I have been informed about the programs and services available at the C4MH.
I understand that not all
services are covered by all funding sources.
Additionally, I understand that my mental health treatment may not include all
services offered.
I will receive care based upon my individual needs.
As the Center offers a variety of services along with
therapeutic modality types that may change over time, I will have an opportunity to review with a C4MH employee and/or my
treatment team the different types of available services, therapeutic interventions within those services and my treatment
plan upon initiation into services and at regular treatment plan updates.
CANCELLATION POLICY.
I understand that it is my responsibility to keep my scheduled appointments with my C4MH providers.
I will call at minimum 24 hours in advance to reschedule any conflicting appointments.
C4MH employees may provide support
with appointment reminders through phone calls, texts and/or mail correspondence; however, if upon review of my
attendance history, I “no-show” or “cancel” on a consistent basis or my C4MH treatment team believes there is a high level
concern with my commitment to treatment, they will review my attendance history and there is a possibility for termination of
services at the C4MH.
If services are terminated, the C4MH will make attempt to notify me in writing.
AGGRESSION POLICY.
I understand that the C4MH is designed to be a safe place. Aggressive behavior is not acceptable.
Aggressive behavior is defined as: physical fighting, pushing, throwing objects, yelling, swearing, or threatening harm.
First Violation:
Leave C4MH property immediately for 24 hours. May keep all scheduled appointments.
Meet with
case manager and/or treatment team to resume services.
Second Violation:
Leave C4MH property immediately for 48 hours. May keep all scheduled appointments.
Meet with
program supervisor/manager to resume services.
Third Violation:
Leave C4MH property immediately and not return until meeting with Area Director or designee to
discuss whether I am benefitting from C4MH services.
Severe/Significant Violation:
Leave C4MH property immediately and may not be allowed to return to services due to
the severe and significant nature of the aggressive act(s).
I understand that any time the C4MH deem appropriate, law enforcement or other emergency responders may be contacted
in order to maintain the safety of all parties.
If services are terminated, the C4MH will make attempt to notify me in writing.
GRIEVANCE POLICY.
I understand that that the C4MH has a Grievance Policy.
I may discuss a complaint with any C4MH
employee to determine whether the complaint can be resolved without filing a formal grievance.
Informal discussion does not
preclude the filing of a formal grievance.
The C4MH employee may assist me at any time during the process but may also
channel the grievance to the appropriate C4MH employee for resolution.
There is no statute of limitations on filing a
grievance.
NOTICE OF PRIVACY PRACTICES.
I understand that as a part of my health care, the C4MH receives, originates, maintains,
discloses and uses individually identifiable health information including, but not limited to, health records and other health
information describing my health history, symptoms, examinations and test results, diagnoses, treatment plans, and billing and
health insurance information.
I acknowledge I have been provided the C4MH “Notice of Privacy Practices”
brochure.
My
rights including the right to see and get a copy of my record, to limit disclosure of my health information, and to request an
amendment to my record, as explained in the Practices.
I understand that I may revoke in writing my consent for release of
my health care information, except to that extent the C4MH has already made disclosures with my prior consent. As a
standard, the Center maintains health records for a length of 10 years.
MENTAL HEALTH RIGHTS IN MONTANA.
I understand that I have mental health rights.
I acknowledge I have been provided
the C4MH “My Mental Health Rights”
brochure.
I understand that this brochure also includes Advocacy Resources through
the State of Montana.
_____________________________
Please initial for acknowledgement
Application for Services – 04-2020
6
APPLICATION AUTHORIZATION
CLIENT PHOTO IMAGE RELEASE.
The C4MH requests the irrevocable and unrestricted right to take a client photograph as
there exists a clinical need to obtain a photo image of C4MH clients and place in the client’s clinical record for purposes of:
treatment, care coordination amongst C4MH employees and to improve quality measures of both the client’s treatment
services and their electronic medical record, while ensuring that the client’s rights to privacy and confidentiality are respected.
Yes, I approve to have my photo taken.
No, I decline to have my photo taken.
SOCIAL MEDIA.
C4MH takes very seriously dual relationships and professional boundary conduct.
Our policy is to not
friend/follow our clients on any social media platform.
We request the right to keep C4MH services in a professional status.
EMERGENCY SERVICES.
I understand that C4MH provides emergency services 24 hours a day, and if I have a mental health
emergency when the C4MH is closed, I can receive after-hours emergency services by calling the Voices of Hope Crisis Hotline
number at 1-800-273-TALK.
TERMS OF AGREEMENT.
I voluntarily agree to the terms and conditions contained herein.
I acknowledge that all the
information provided is true and correct. Further, I understand that I am required to pay my assigned fee at each visit and that
services may be terminated due to non-payment of assigned fees.
Under penalties of perjury, I certify that the information
presented in this Application for Services is true and accurate to the best of my knowledge and belief.
I further understand
that providing false representations herein constitutes an act of fraud.
False, misleading, or incomplete information may result
in the termination of the services.
I agree that during the time that I am a client at the C4MH, I will keep the C4MH informed of my current address,
phone number, employment status and all information pertinent to my mental health progress.
If at any time I decide to stop treatment at the C4MH, I will inform my treatment team.
I understand that I may revoke consent to treatment at any time.
_______________________________________________________
_______________
Client's signature
Date
_______________________________________________________
_______________
Parent/Legal Guardian (for children 17 and under)
Date
_______________________________________________________
_______________
Witness
Date
For office use only
The client was provided the Notice of Privacy Practices and Mental Health Rights &
Advocacy brochures.
_____________________________________________________
_______________
C4MH Employee Signature
Date
Sliding Fee Applications
Approved
Not Approved
Reason: ______________________
Application for Services – 04-2020
7
MIDAS
(Mental Illness, Drug and Alcohol Screening)
Please answer as related to the last 6 months only.
Yes
No
1. Do you feel that you have a problem with your use of drugs and/or alcohol and/or
gambling?
Yes
No
2. Do you use drugs, alcohol, or gambling even though your doctor or other providers
recommend that you do not?
Yes
No
3. Is your family concerned about your drugs and/or alcohol or gambling?
Yes
No
4. Are your providers concerned about your drugs and/or alcohol or gambling?
Yes
No
5. Have you had legal problems or engaged in illegal activity (other than using drugs) due to
drugs and/or alcohol or gambling?
Yes
No
6. Have you had medical problems related to, or worsened by, drugs and/or alcohol or
gambling?
Yes
No
7. Do you use drugs and alcohol or gambling to relieve mental health symptoms?
Yes
No
8. Do you find that using drugs and/or alcohol or gambling worsens your mental health
symptoms?
Yes
No
9. Do you have problems taking your psychiatric medication as prescribed because of drugs
and/or alcohol use or gambling?
Yes
No
10. Have you gotten in trouble, including getting in trouble at a mental health treatment
program, because of drugs and/or alcohol or gambling?
Yes
No
11. Have you had ER visits or psychiatrics hospitalizations that were connected to drugs
and/or alcohol use or gambling?
Yes
No
12. Do you every feel guilty about your drugs and/or alcohol use or gambling?
Yes
No
13. Have you experienced withdrawal symptoms or intense cravings to use drugs or alcohol
or to gamble?
Yes
No
14. Have you attend self-help (e.g., 12 Step) meetings relating to drugs and/or alcohol use or
gambling?
Yes
No
15. Have you received any addiction treatment, including detoxification?
Yes
No
16. Have you felt unable to control your use of any drug or alcohol or gambling?
Yes
No
17. Do you consider yourself to be an alcoholic or drug addict or gambling addict?
Yes
No
18. Do you engage in the use of alcohol, drugs, or gambling activity three times a week or
more?
*Adapted with expressed permission for use from Dr. Ken Minkoff, MD developer of the MIDAS Screening Tool.
*Client self-reported form is located in electronic Clinical Record with Application documents.
*See Intake Assessment under Substance Abuse section for full clinical assessment.