Nike Carli, LCSW-R ~New Patient Telehealth Forms

Nike Carli, LCSW-R

5500 Main Street, Suite 259, Williamsville, New York 14221 Phone: 716-633-6900
New Patient Telehealth Forms
Please provide the following as best you can. I appreciate your willingness to cooperate in helping me obtain your history and information.

Patient Information
Date*

MonthDayYear
Date
Name*

First NameLast Name
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Birth Date*

MonthDayYear
Marital Status*
Number of years married or cohabitating:
Spouse/Companion’s Name
Employment Status*
Employer's Name
Employer's phone number
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name: *
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about me? (Who referred you?) *

Patient Bill of Rights, Confidentiality and Treatment Form
I have received a copy of the Patient Bill of Rights and Treatment Information, and have been given an opportunity to review it. *
I have received a copy of the Patient Bill of Rights and Treatment Information, and have been given an opportunity to review it.

Notice of Privacy Practices
I have received a copy of the Notice of Privacy Practices, and have been given an opportunity to. review it
I have received a copy of the Notice of Privacy Practices, and have been given an opportunity to. review it*
Signature

Clear

Authorization For Release Of Healthcare Info Primary Physician
Name*

First NameLast Name
Birth Date*

MonthDayYear
I authorize and request healthcare information for the above mentioned patient be release to Nike Carli, LCSW-R
I authorize and request Nike Carli, LCSW-R to release healthcare information for the above mentioned patient to:
Primary Care Physician's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Purpose: Coordination of treatment.

I hereby authorize the release of the above information from my record. I understand that the information to be released from my record is confidential and protected from disclosure. I also understand that I have the right to cancel my permission to release information at any time before it is released. I also understand that my consent to release information will expire:
Upon discharge form treatment
To: 90 days from this date
Signature

Clear
Patient Signature*
Date Signed*

MonthDayYear
Date

Use of E-mail Authorization
Use of E-mail Authorization

Many patients find it convenient and helpful to communicate with me by e-mail. While I welcome such communications, due to the inherent risks involved in e-mail use, it is important to understand the following:
I authorize Nike F. Carli, LCSW-R to communicate with me by emailI do not authorize Nike F. Carli, LCSW-R to communicate with me by email
E-mail (only provide if you authorize)

Confirmation Emailexample@example.com
Signature

Clear
Patient Signature*
Date Signed*

MonthDayYear
Date

Telehealth Authorization
I understand that telehealth involves the communication of my behavioral health information in an electronic or technology-assisted format.

I understand that I may opt out of the telehealth visit at any time. This will not change myability to receive future care at this office.

I understand that telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage.

I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment isreduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:

•It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures.

•Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.

•Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.

I agree that information exchanged during my telehealth visit will be maintained by Nike Carli, LCSW-R

I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others.

The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.

I understand that electronic communication cannot be used for emergencies or time-sensitive matters.

To the extent permitted by law, I agree to waive and release my healthcare provider and her practice from any claims I may have about the telehealth visit.
I have read this notice and I authorize Nike F. Carli, LCSW-R to provide treatment using Telehealth.
Signature

Clear
Patient Signature*
Date Signed*

MonthDayYear
Date

Photo ID
Please provide a copy of a valid photo ID

Upload - scan and upload using the "Browse Files" button below

Fax to: 716-633-6902

Mail to: Nike Carli, LCSW-R

5500 Main Street, Suite 259

Williamsville, New York 14221
I will provide my photo ID in the following manor*

UploadFaxMail
Please upload your photo ID

Browse Files

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Insurance Card
Please provide a copy of your insurance card (front & back) if applicable

Upload - scan and upload using the "Browse Files" button below

Fax to: 716-633-6902

Mail to: Nike Carli, LCSW-R

5500 Main Street, Suite 259

Williamsville, New York 14221
I will provide my insurance card in the following manor*

UploadFaxMail
Please upload your insurance card

Browse Files

Cancelof

Submit
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