New Patient Registration Form

New Patient Registration
WELCOME TO LEGACY BEHAVIORAL HEALTH!

Your Privacy and Security are important to us. The information on this form is confidential, encrypted and secure.
Are you completing this form on behalf of a family member?*

YesNo
If yes, please provide your name, phone number and email address*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Patient Information*

First NameMiddle NameLast Name
E-mail*
Sex*
Date of Birth*

MonthDayYear
Contact Number:*

Area CodePhone Number
Marital Status*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In case of emergency...
Emergency Contact:*

First NameLast Name
Relationship*
Contact Number*

Area CodePhone Number
Please provide the name, phone number and address of your primary care provider (PCP.
Taking any medications, currently?

YesNo
If yes, please list it here
If you are employed, please provide the name of your employer.
How were you referred to LEGACY?
Which one of our providers would you like to make an appointment with?*

Darwin Davis, LMSWTyece Drake, MHC-LPNicole Genc, LMSWOlivia Lane, LMSWLisa Phillips, LCSW, CASAC-MKortney Conley, BAPamela Medina, BAMikayla Whalen, BAChloe Ricco, BSLissette Stapleton, LMSWJames Gartner, LMSWAbby Newton, LMSWSarah Gardiner, LMSWJustine Pascual, LMSWRaphael Revella, LCSWKaitlyn Curtin, LMHCMykahla Collins, LMHCEric Mercadante, LMSWHillary Snare, LMSWDr. Melanie Styles, PhD Ed, LMHCSally D'Alessandro, LMSW, MAJessica Benedetto, LMHCSharon Keenan, LCSWKaitlyn Curtin, MHC-LPGabriella Melillo, LCSWCesar Vasquez, LCSW-RTamika Hardwick, LCSW, LMSWCamille Ramos, MHC-LPRasheed Anderson, LMSW, LCSWKylie McKeighan, LMHC, RNNicola Most, LMHCCarla Natale, LCSWSherman Stovall Jr, LCSW-R, MA, CEAP, Q-SAP, C-DER, EAS-CI don't knowOther
What types of services are you looking for?*

Consultation/CounselingHealth & Wellness CoachingLife CoachingI'm not sure
Please list any medical conditions (including behavioral health diagnoses') you currently have.
Do you have allergies to medications or food? If yes, please list below.
Have you ever been psychiatrically hospitalized?

YesNo
If so, what is the name of the hospital and the year this occurred?
Please upload a copy of your Drivers License/Passport or ID card.*

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Type of pay?*

Insurance planPrivate pay
Who is the policyholder on your insurance plan (can be a parent, spouse or yourself)? If you are the owner of the policy, then type your name.*
Policyholder Date of Birth*

MonthDayYear
Date
What is the name of your insurance plan (i.e. CDPHP, Aetna, Cigna, etc?*
What is your Policy# ?*
What is your Insurance Group #?*
What is your copay? Or your deductible?
Please upload a copy of the FRONT and BACK of your Insurance Card. *

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Please review and sign acknowledgment that you have read and understand our Practice Policy's.
PLEASE READ THE FOLLOWING

Cancellation Policy

We ask that you please call our offices at least 24 hours before your office visit if you must cancel or reschedule an appointment. If you must cancel an appointment for any reason, please let our staff know as soon as possible so that we may offer that appointment to another patient in our community that is in need of support. Please remember that 3 consecutive missed appointments may result in an automatic discharge from Legacy Behavioral Health.

Violators of this cancellation policy will be assessed a $50 violation fee. All patients of Legacy Behavioral Health are required to keep a secured and confidential credit card on file with our administrative office in the event of a violation to this policy. In lieu of keeping a credit card on file, patients also have the option of making a $50 refundable cancellation deposit which shall be returned to them upon termination or discharge from the practice (given that the patient has no policy violations). If a patient selects the “cancellation deposit option”, they will be required to replenish their deposit upon each violation. Refusal to adhere to this policy will result in our offices being unable to secure an appointment for you.

Respect

All parties having any business with Legacy Behavioral Health Inc., its subsidiaries, or its partners deserve to operate in a calm, respectful, and restorative environment.

Discriminatory practices, bullying, inflammatory remarks, rude behavior, profanity, harassment of any kind (including sexistor racial overtures) and civil disorder will never be tolerated at Legacy Behavioral Health under any circumstances.

Therefore, all patients of Legacy Behavioral Health Inc., are required to conduct themselves in a respectful manner at all times. Employees of Legacy Behavioral Health will not engage any patient in a rude or disrespectful manner regardless of whether they are encountering someone who is behaving in a disruptive or uncivil manner.

Violators of this policy will be required to leave the premises immediately and may be effectively discharged from the practice and not be allowed to return for services.

In the event that our Providers or staff encounter a patient that is in violation of this policy, ALL treatment and communications (telehealth included) will cease immediately and the incident will be referred to our internal review process and leadership team.

Violators of this policy can expect to be contacted by a member of the leadership team; and they will relay the groups final disposition on the matter.

Emergencies

Staff will respond to voicemail, texts and emails within 24-48 hours (excluding weekends and holidays). Legacy remains committed to everyone's health and safety. If you are unable to reach a member of our staff through our toll free office number, (844)-2-LEGACY, please call 911, your local emergency room, or the Capital District Psychiatric Center at 518-549-6500.

Office Visit Policy

All patients will be required to present a valid insurance card (if applicable) and driver's license or photo ID. Payment is required before, or at the time of service of each appointment.

Payment Policy

Payment is required at the time of service for all services. Charges incurred are ultimately determined to be the patient's responsibility, including co-payments. Payment may be made by cash, check, MasterCard, Visa, Discover, or American Express. You may also pay your bill by phone.

Insurance Claims/Billing

Legacy Behavioral Health, participates with some major insurance carriers. As a courtesy to our patients, we will file insurance claims for those insurances with which we participate. Please remember, any amount not covered by insurance is ultimately the patient's responsibility. Please contact your insurance company to confirm that we are a participating provider with them. The insurances that we accept, change depending on the provider administering the service. We require that you bring your insurance card and photo ID to all visits. All Clinicians at Legacy Behavioral Health are assigned a Clinical and Billing Supervisor. Legacy has the following Clinical and Billing Supervisors: Sherman Stovall Jr, LCSW-R; Cesar Vasquez, LCSW-R; Dr. Melanie Styles, LMHC and Monica D'Agostino, LCSW-R, Sharon Kennan, LCSW, Carla Natale, LCSW, Jessica Benedetto, LMHC. I understand that Legacy Behavioral Health may be authorized to submit insurance claims to insurance companies under the designated supervisor of my assigned clinician.
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Patient Consent & Treatment Contract

* As a participant in treatment for counseling and/or medications:

I freely and voluntarily agree to accept this treatment contract as follows:

1. I agree to keep and be on time for all of my scheduled appointments with the Group of Providers at Legacy Behavioral Health.

2. I agree to adhere to the payment policy outlined by this office. Payments must be made via cash, online payment, credit card or certified check or cashier check.

3. I agree to conduct myself in a courteous manner in the doctor's office.

4. I agree not to sell, share, or give any of my medications to another person. I understand that any such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.

5. I agree not to deal, steal, or conduct any illegal or disruptive activities on the premisis of Legacy Behavioral Health, Inc.

6. I agree to take my medication as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor.

7. Violations to the company's cancellation Policy will result in a $50.00 fee that will be assessed immediately.

8. Legacy does not take any responsibility for any failure of Insurance Reimbursements. You will be billed for any balances you are responsible for.

9. You must let your Provider or the staff know of any changes in your insurance policy, otherwise you will be responsible for any charges incurred.

10. If you have not been compliant with your treatment visits for a period of 90 days, you may be terminated or discharged from treatment with Legacy Behavioral Health.

11. If you are terminated from the practice you may not be able to return to the practice for any services. You will be referred to other providers whom provide similar services.

12. We understand that violations of the above may be grounds for termination of treatment.

13. I authorize Legacy Behavioral Health to charge my debit/credit card/HSA card for any outstanding balances on my account. If I do not want to be charged I must call the billing office at 518-245-3652 and notify staff of this request prior to my visit.

* I agree the above is reviewed and also accurately reported information and by signing my name, I affirm my acknowledgement of the Treatment Contract by Legacy Behavioral Health.
By checking the box you agree to receive SMS text messages from Legacy Behavioral Health related to the following: appointment reminders, follow-up messages, billing inquiries, appointment scheduling. Message frequency may vary. You may receive up to 5 SMS messages per week regarding your appointment or account status.Please note that standard message and data rates may apply depending on your carrier’s pricing plan. These fees may vary if the message is sent domestically or internationally. You may opt-in to receive SMS messages from Legacy Behavioral Health verbally during a conversation or by submitting an online form. You can opt out of receiving SMS messages at any time. To do so, simply reply "STOP" to any SMS message you receive. Alternatively, you can contact us directly to request removal from our messaging list by calling 518-535-9175. If you are experiencing any issues, you can reply with the keyword HELP. Or, you can get help directly from us by calling 518-535-9175. Learn more on our privacy policy page and Terms and conditions at https://www.mylegacynyc.com/privacy-policy

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