Patient Intake Form

HIPAA Privacy Authorization

I understand that Vantage Point Behavioral Health LLC ("VPBH") will use and disclose my protected health information (PHI) for treatment, payment, and healthcare operations as described in the Notice of Privacy Practices provided to me.

I authorize VPBH to:

• Use and disclose my health information for the purposes of diagnosis, treatment, and care coordination
• Share information with insurance companies for billing and payment purposes
• Contact me via my preferred method of communication regarding appointments and services
• Leave messages related to my care at the contact numbers provided

I understand that I have the right to revoke this authorization at any time by submitting a written request, but that revocation will not affect information already used or disclosed.

Financial Responsibility and Payment Agreement

I understand that I am financially responsible for all services rendered. I agree to:

• Pay all co-payments, deductibles, and coinsurance amounts at the time of service
• Pay for services not covered by my insurance plan
• Provide accurate insurance information and notify VPBH of any changes
• Pay a $50 fee for missed appointments or cancellations with less than 24 hours notice
• Be responsible for any unpaid balances if insurance denies or partially covers services

I authorize VPBH to release information to my insurance company for billing purposes and to receive payment directly from my insurance company.