IHG Continuing Care Patient Transfer Form Step 1 of 8 12% Which provider do you wish to schedule with? Elizabeth Goebel, LMHC Barbara Logan, DNP, FNP-BC, PMHNP-BC Jennifer Myers, LCSW Daniel Shepler, PMHNP-BC Francia Siler, LCSW Jenn Stepic-Wenzel, LMHC Patient Demographic InformationPatient's Name:(Required) First Last Patient Prefers to Go By (Nickname): Patient's Date of Birth:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient's Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone:(Required)Other Phone:Email: Is the patient a minor?(Required) Yes No Parent/Guardian Name:(Required) First Last Parent/Guardian Phone:(Required)Parent/Guardian Email Address:(Required) Legal Sex:(Required) Female Male Gender Identity: Female Male Trans-Female Trans-Male Non-Binary Other Sexual Orientation: Heterosexual Bisexual Gay Lesbian N/A Other Insurance InformationDo you have insurance that you would like us to file on your behalf?(Required) Yes No Insurance/Private Pay(Required) Anthem / Blue Cross Blue Shield Cigna ComPsych Midwest Behavioral Health Network Sagamore / IHN United Healthcare / UBH / UMR Other Please List the Name of Your Insurance:(Required) Our practice is OUT OF NETWORK with the insurance you selected. Your scheduling deposit will be applied to your initial visit. Any balance over the deposit amount will be due in full at the time of service. We will gladly file your claims for possible out-of-network reimbursement as a courtesy.Notice:(Required) I understand the statement below and wish to continue.Network Participation Pending: This process may take between 30 to 120 days. For up-to-date information, please visit our website and click on the PROVIDER SEARCH tab to check the network status of your provider. If you have any questions, please don't hesitate to contact us at 317-843-9922 or by emailing us at appointments@indianahealthgroup.com.Primary Insured Name:(Required) Identification Number:(Required) Group Number:(Required) Insurance Phone Number:(Required) Claims Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Upload a copy of the FRONT & BACK of your insurance card:(Required) Drop files here or Select files Max. file size: 128 MB. Telehealth Appointment ConsentThis consent is for all telehealth services provided to me by providers of Indiana Health Group. Telehealth is the use of the Internet to provide remote health care for patients. This telehealth appointment may be for diagnosis, continuity of care, treatment, testing, or medical consultation deemed necessary by my provider or me. My provider will be communicating with me remotely via the Internet using doxy.me web-based audio-video software (referred to in this form as Telehealth Appointment).Consent(Required) I agree to the statement below.(Required) I understand that during a Telehealth Appointment: Details of my medical history and personal health information may be discussed with me and/or other health professionals. Audio, video, or photo recordings containing medical details may be transmitted via secure channels and those details may become part of my permanent medical record. All confidentiality protections granted to me by various state and federal laws also apply to my care during this appointment. Industry-standard network and software security protocols are in place that protect the privacy of the communication and safeguard my transmitted information against eavesdropping and corruption. There may be security and privacy risks associated with Internet-based communications. There are benefits and limitations when compared to a traditional in-person visit because I will not be in the same room as my healthcare provider. Either my Healthcare Provider or I can discontinue the Telehealth Appointment if either of us feels that the information obtained through remote communications is not adequate for diagnostic decision-making or for providing the care I desire. In addition to my Healthcare Provider, I will be informed of any other person(s) who may be present during the appointment and have the right to have them leave the viewing and listening area. To maintain my privacy, I need to ensure that my viewing and listening area is limited to myself and any other person that has a need to participate during the virtual appointment. Due to the limitations of telehealth that are out of my control (such as an unreliable internet connection), I will call local authorities (9-1-1) to assist me with a medical emergency. I have the right to omit or withhold specific details of my medical history/physical examination that are personally sensitive. My Healthcare Provider may advise me to seek immediate treatment or determine that there is a medical emergency and, as such, local authorities may be given my personal details to assist me. The communication is privileged and confidential, and I will not record the audio or video without first seeking the permission of my Healthcare Provider. Consent(Required) I agree to the statement below.(Required)Therefore, by consenting to this Telehealth Appointment: I wish to engage in remote audio-visual communication with my Healthcare Provider. I understand the risks and benefits of using Internet-based communications and that no results can be guaranteed. I acknowledge that if the Healthcare Provider believes that remote communication is insufficient for treatment, consultation, or evaluation, then I will be offered alternate services or options. I understand that I may be responsible for co-payments, deductibles, or other charges from my Healthcare Provider, and additional charges may occur for services related to this appointment. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Healthcare Provider. I can ask direct questions to my Healthcare Provider about this appointment, including details about the Healthcare Provider's privacy policy. If my questions are not answered to my satisfaction, I have the right to terminate the appointment. I am at least 18 years of age. Signature(Required) Patient Policies & Consent to TreatPATIENT POLICIES & CONSENT TO TREAT Please visit our website, indianahealthgroup.com. Click on FORMS located under the PATIENT INFORMATION tab. Please review the following documents: Patient Information, Policies, Terms & Conditions Privacy Practices Consent(Required) I agree to the statement below.(Required)By my signature below, I agree to the following: I have read, understand, and agree to the terms of the documents listed above. I have provided current and accurate information on all documents included in the patient registration process. I agree and consent to participate in the treatment and services offered and provided by Indiana Health Group, and all affiliate providers of Indiana Health Group. Indiana Health Group (IHG) reserves the right to revise information to our policies. Our most current policy is always available on our website, indianahealthgroup.comSignature(Required) ContactIs there anything else you would like to share with us prior to scheduling?
