Assessment Application - Mat-Su - Set Free Alaska - Alcohol and Drug Treatment Alaska

Intake Information

Initial Contact: Check one*

City / Village: Check one*

Source of Referral: Check one*

Only Required if Female: Pregnant?

Yes
No

If Yes: Due Date

Injection Drug User (within the last 12 months)*

Yes
No
Unknown

Primary Presenting Problem:*

Alcohol & Drugs
Alcohol
Drugs

Secondary: (Specify From List Below. If none put N/A)*

Tertiary: (Specify From List Below. If none put N/A)*

(Alcohol & Drugs Alcohol Only; Drugs Only; Suicide attempt/threat; Child abuse victim; Sexual abuse victim; Domestic violence victim; Eating disorder; Thought disorder; Depression; Social/interpersonal (not family); Coping with daily roles/activities; Marital; Family (non marital); Medical/somatic; Psychological/emotional; Financial; Poverty; Child abuse perpetrator; Sexual abuse perpetrator; DV perpetrator; None; Other; Unknown)

Presenting Problem(s) in clients own words: Why is the client seeking services?*

Special Initiative: Check all that apply*

Consent*

By signing and submitting this form, I am giving consent to Set Free Alaska to enter my identifying information on Alaska’s Automated Information Management System (AKAIMS). Furthermore, I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the agencies identified above may not condition my treatment on whether I sign a consent form, but that in certain circumstances I may be denied treatment if I do not sign a consent form.

Signature*

Client Financial Responsibility Agreement

Thank you for choosing Set Free Alaska, Inc. (hereafter referred to as “SFA”) as your treatment provider. We are committed to providing you with quality services. SFA must obtain a valid copy of your identification, current Insurance information and proof of income when applicable.

Insured (Including Medicaid): All services are provided to you with the understanding that you are responsible for the cost regardless of your insurance coverage. If you would like to know the cost of a service, please inquire prior to treatment. Please be aware that not all services are a covered benefit with different insurance companies. You are responsible for knowing what services are or are not covered.

**Important Notice Regarding Medicaid.

** Please be aware that, at this time Medicaid will only pay for one assessment every six months. The assessment must have a diagnosis or level of care for Medicaid to pay for it. If you don’t have a diagnosis or level of care you will be billed for an assessment at the sliding scale fee. **

Your insurance policy is a contract between you, your employer, and the insurance company. We are NOT a party to that contract. It is your responsibility to notify this office immediately if your insurance coverage changes. It is your responsibility to understand your coverage and benefits, including pre-certifications, referral and authorization requirements, and to be sure all insurance information is current.

When possible, we will bill your primary insurance company (including Medicaid) as a courtesy, but you are still ultimately responsible for payment of all services you receive. If your insurance company does not respond within 60 days, we will follow up with an inquiry on your behalf. If, however, your insurance does not respond within 60 days of claim submission, an invoice will be sent to you. You should call your insurance to question why the claim is not paid. Our office will assist you only after you have contacted your insurance.

Insured/Non-Insured Payments: We accept cash, check, debit card, and credit cards for MasterCard and Visa.

Insured: Unless a payment plan has been agreed upon prior to the date of service, we will collect your deductible, co-pay, and payment for any uncovered services as well as the client’s portion as determined by insurance at the time of service.

Non-Insured/Under-Insured: If you do not have medical insurance the following applies: Unless a prior financial agreement plan has been signed and payments are current, you will be responsible for a minimum payment at the time of service for the service to be received that day, as well as any previous outstanding balance. We offer a 20% discount for payment in full at time of service.

Sliding Scale: I understand that to be eligible for the sliding fee scale I must provide current proof of income. (Most resent paystub or tax return). I also understand that I must notify Set Free Alaska of any changes or increases that cause me to be no longer eligible for sliding scale.

No-Show Fee: There is a $25.00 fee for missed appointments not cancelled within 24 hours of the scheduled appointment time. These charges are your responsibility and cannot be billed to insurance or Medicaid. This fee maybe waived situationally.

Collection Fee: There is a $25.00 fee for collecting UA samples using an instant-read cup. Use of Instant Read cups are at the discretion of the counselor providing the service.

ASAP Clients: In the event that there is an outstanding balance after sessions are complete, SFA will report to ASAP that client has attended all recommended sessions; however, is not treatment complete due to an outstanding balance.

**We do understand that temporary financial problems may affect timely payment. We encourage you to communicate any such problems with the office manager. Please call (907) 373-4732 for account management. **

Release of Information: I assign benefits of my medical insurance contract or Medicaid to SFA and authorize payment directly to SFA. I authorize SFA to release medical information to payers as required for payment of claims for medical services.

Delinquent Accounts: Any unpaid charges over 90 days old will be considered for an outside collection agency. The Collection agency will receive client identifying, contact and financial information. You are responsible for any collection, legal, or court fees incurred in the collections process. Your clear understanding of our Financial Policy is important to our relationship. Please ask if you have any questions about our fees, Financial Policy, or your financial responsibility. We will discuss our professional fees at any time.

Consent*

I have read and understand the payment policy and agree to abide by its guidelines:

Client Name*

First Last

Client / Guardian Signature*

Name

This field is for validation purposes and should be left unchanged.

Set Free Alaska

Phone 907-373-4732

Fax 907-746-4749

Set Free Assessment Form - Mat-Su

Step 1 of 3

Client Profile

Demographics

Intake Information

Client Financial Responsibility Agreement