Forms

         Please understand that on your Initial Appointment at the office we will require some basic forms to be filled out by you.

This process should take approximately 15 minutes prior to your appointment.

Here are the forms you will need on your first appointment.  Please feel free to print them out to make the initial appointment check-in process smoother and easier.

(Only Complete one of the four forms below.)

Metrolina Adult Registration ages 18 and up

Metrolina Child Registration ages 17 and below

Metrolina Adult Dietitian Registration ages 18 and up

Metrolina Child Dietitian Registration ages 17 and below

This is also needed for your information.  Please print and sign the signature page, which is the last page of the document.)

Metrolina Notice of Privacy Practice

This next form may be needed from time to time in order to allow us to release information to parties that you might want us to.  Please understand Metrolina Psychotherapy Associates respects with utmost seriousness, and desires to strongly protect your private health care information.  We will release information by your request, even in that instance we do so judiciously.

Metrolina Release Form

We ask that you bring your drivers license and insurance card on the first visit.

In order to process the Initial Appointment smoothly we ask that you contact your insurance carrier to acquire any necessary authorizations that are required for your health care.  Some insurance carriers do not require this, but some certainly do.

Steps to Contact Your Insurance Carrier and Important Terms to Understand:

1.)  Look on the back of your insurance card for the customer service number. 

2.)  Call your carrier and request information about your mental health benefits – especially authorization of services.

  • Authorization of services is required for certain insurance companies prior to you being seen in this office.
  • If this is required, please ask your carrier for the authorization number (typically this is a long number) that is assigned to you.
  • Please gie us the authorization number so Metrolina Psychotherapy Associates, PA can bill your insurance carrier immediately after services are provided to you.

3.)  Other terms that you may need to understand:

  • Out-of-pocket:  This is money that you pay to the clinic that is not reimbursed by your insurance company.
  • Co-Pay:  This will be your payment to us on the day of your visit that is required by the insurance company.  If your insurance carrier requires this, it is so that they are not the only one paying for the visit.
  • Co-Insurance:  This is similar to co-pay.
  • Deductible:  This is an amount the insurance company requires you to pay out-of-pocket in a given calendar year before they will pay any amount toward your visit with us.
  • A calendar year is any particular 12-month time frame.  Example:  One insurance company will have their calendar year January to December, while another insurance company has their calendar year from March to February.
  • Annual Limits:  “a cap on the benefits your insurance company will pay in a year while your’re enrolled in a particular health insurance plan.  These caps are sometimes placed on particular services such as prescriptions or hospitalizations.  Annual limits may be placed on the dollar amount of covered services or on the number of visits that will be covered for a particular service.  After an annual limit is reached, you must pay all associated health care costs for the rest of the year,”  Healthcare.gov