451 Andover Street, Suite 130 North Andover, MA 01845
Phone: 978.683.6065 Fax: 978.683.6055
Client Information
Client’s Name: _____________________________________ DOB: ____________
Address: _____________________________________________________________________________
Age: ________
City, State, Zip: ____________________________________________ Phone: ___________________
Work Phone: ______________________ Mobile: ______________________ Male or Female
Email: ______________________________________ Best way to contact you? ____________________
Referral Source: _______________________________________________________________________
Party Responsible for Payment (if different than above)
Custodial Parent or Legal Guardian Name: _________________________________________________
Address: _____________________________________________________________________________
City, State, Zip: ____________________________________________ Phone: ___________________
If you DO NOT have Blue Cross/Blue Shield and intend to continue with Dr. Boisture as PRIVATE PAY, please initial here, _________ and fill out the payment information section below as well as provide your current insurance information to us for any necessary prescription authorizations.
BLUE CROSS / BLUE SHIELD INFORMATION:
INSURED’S NAME:____________________________________________________________________
INSURED’S I.D NUMBER ______________________________________________________________
INSURED’S DOB _____________________________________________________________________
PLAN TYPE: ___________________ CO-PAY: $_____________________
PRESCRIPTION BENEFITS MANAGED BY: __________________________________________
PRESCRIPTION ID #:_____________________________________________________________
PREFERRED PHARMACY:____________________________________________________________________
___________________________________________________________________________________________
PLEASE PROVIDE YOUR CARD(S) TO THE HEALTH SERVICES COORDINATOR FOR COPYING
PAYMENT INFORMATION
NAME ON CARD: ____________________________________________________________________
MC or VISA CARD NUMBER____________________________________________________________
EXPIRATION DATE: MONTH_________/YEAR___________ CVV: ____________________________
I give permission to maintain this card on file and for Jennifer Boisture, MD to process all future charges using this card, I will notify Dr. Boisture with updated credit card information as it becomes available
Signature____________________________________________________ Date: ____________________

GENERAL INFORMATION
With the exception of Blue Cross Blue Shield of Massachusetts, I do not contract with third party insurance companies. I realize you have a choice of mental health providers and apologize for any inconvenience. This decision is based on my commitment to providing the best possible treatment, while minimizing the impact of managed care and insurance restrictions. Therefore, except for patients currently eligible for behavioral health coverage under a Blue Cross Blue Shield of Massachusetts insurance plan, services are provided on a private-pay basis only, fees are collected at the time of service and are payable by cash, check or credit card. Depending on the form of treatment, my rates are generally $200-$300/hour.
If you are seeking reimbursement from a third party on your own, I am not able to be involved in that process. We can assist you by providing a statement of services, dates, charges, procedures and diagnostic codes, but I cannot complete HICF forms, fill out authorizations or referral forms, make phone calls or take part in an appeals process for payment.
CANCELLATION POLICTY
I require a minimum of 24 hours notice of cancelled appointments. Time set aside in my schedule for your appointment is reserved only for you and you will be charged $100 for any missed or cancelled appointments without 24 hour notice. _____________ (Initial here)
In the case of two missed appointments without adequate notice, you must pay any outstanding balance on your account prior to scheduling a new appointment. ___________ (initial here)
ADDITIONAL SERVICES
Writing letters and clinical reports, completion of disability forms or extensive phone calls (billed in increments of 15 minutes) will generally be charged at a rate of $200/hour.
TESTING
Testing cost varies dependent upon the recommended testing modules. Costs will be discussed cased on the clinician’s recommendations prior to administering the tests so that you may make an informed decision.
LEGAL TESTIMONY/REPORT WRITING
Sometimes during the course of evaluation and treatment, a client may request a letter or report to a third party for legal purposes or request that deposition or legal expert witness testimony be provided by their treating clinician. If it is determined such action is in the best interest of the client, the clinician will proceed with written consent from the client, to offer such services at a rate of $300/hour plus expenses discussed in advance, payable at the time of services. Travel time will be billed at the same hourly rate.
In the event a formal subpoena for records or testimony is received the policy is as follows: 1) The client will be notified in writing and provided with a copy of the subpoena; 2) The client must either provide the clinician with a waiver of objection to the subpoena in writing; OR 3) the client must indicate an objection will be filed with the court by the client’s attorney with a copy sent to the clinician; AND 4) if an objection to the subpoena is to be filed with the court it is the responsibility of the client to do so. All services provided and expenses incurred by the clinician for court-related issues, including but not limited to contact with attorneys, depositions, travel and courtroom proceedings will be charged to the client as per regular professional fees and payment policies. Payment in fill is required prior to release of legal documentation.

I have read and agree to abide by the policies as written above.
Print Name
Signature
Date
_________________________________________________________________________________________________________________ Created
080210 Jennifer Boisture, MD, JD
CLIENT SERVICES AGREEMENT (HIPAA)
This document contains important information about our professional policies regarding privacy protection, use and disclosure of your Protected Health Information (PHI). These policies are in accord with the Health Insurance Portability and
Accountability Act (HIPAA). Under HIPAA, we are required to provide you with this information and obtain your signature acknowledging we have provided you with this information. We are happy to provide a dcopy of this document if requested.

Limits on Confidentiality
The law protects the privacy and confidentiality of all communication between a client and the client’s clinician(s). In most circumstances we can release information about you (or your child) only with your written authorization. There are a few exceptions to confidentiality and situations in which information may be released without authorization or consent. Parents hold confidentiality rights of children under the age of 18 who are not emancipated. For the sake of clarity, “you” also refers to your child if you are here receiving services for your child. In divorce situations, both parents have equal access to their child’s records, even if one parent has sole legal custody.
Under HIPAA, use or disclosure of your PHI for the purposes of treatment, payment or health care operations requires your consent. Your signature on the client registration form provides consent for these purposes. Treatment refers to services we provide which may include eliciting personal information from you or about you through interview, testing, documentation or consultation with other clinicians intended to serve your health care needs. We are mandated by law to report to the appropriate agencies suspected neglect or abuse of children under the age of 18, individuals with mental or physical disabilities and elders. We may be required to provide additional information once making such a report. If you (or your child) appear to be at clear or immediate risk of self-harm or harming an identified person, we must take reasonable precautions to insure safety. These precautions may include warning a potential victim, notification of law enforcement or arranging for hospitalization and may include disclosure of PHI without your consent or authorization, which is permitted under the law in these circumstances. If you file a Worker’s Compensation claim, your records relevant to that claim can be requested and provided to your employer, insurer or the Department of Worker’s Compensation. The Board of Registration of
Psychologists and the Board of Registration of Medicine have the power to subpoena relevant records when necessary should your clinician be the focus of an inquiry. If you are involved in court proceedings, unless there is a court order, your written authorization is required from you or your legal representative in order for us to release information. If your evaluation is court-ordered, or there is a court order for your information, we are obligated to release your information.
Client Rights and Clinician Duties
You have the right to request restrictions on the disclosure of your PHI. We are not required to agree to a restriction you request, but will make every effort to do so, within the legal limits and exceptions of confidentiality. You have the right to request the location at which you receive communications involving PHI, such as an alternative address or phone number.
You have the right to request in writing to examine and/or receive a copy of your records, unless we determine that access would be a danger to you. In that situation, you have the right to a summary of the record and you can request your record be sent to another mental health provider or to your attorney. You have the right to request an amendment to your record. We may deny your request, but can document your concerns in the record. Your rights include requesting an accounting of disclosures of PHI for which you have provided neither consent nor authorization.
Email Communications
Dr. Jennifer Boisture, MD, occasionally communicates with patients via email for their convenience, but Dr. Boisture will not make specific treatment recommendations via email and cannot ensure complete confidentiality of email communications.
Therefore, it is generally recommended patients restrict such communications to general requests for information and scheduling appointments. If you choose to include PHI in email communications with Dr. Jennifer Boisture, you assume the risk this information may not remain completely confidential.
We are required by law to maintain privacy of PHI and provide you with this notice of legal duties and privacy policies.
Client/Parent: ___________________________________________ Date:________________________________________________________

ASSIGNMENT OF BENEFITS
(FOR PATIENTS WITH BLUE CROSS BLUE SHIELD INSURANCE ONLY)
This is a direct assignment of my rights and benefits under my insurance policy with Blue
Cross Blue Shield. I hereby request relevant payments of insurance benefits be made on my behalf to Jennifer Boisture, MD, JD for services provided. I authorize Dr. Boisture to release as necessary to Blue Cross Blue Shield any medical information needed to determine the benefits payable for related services. This authorization shall be considered valid for the duration of my treatment with Dr. Boisture. A photocopy of this authorization will be considered as effective and valid as the original.
I understand I will be personally responsible for any amount denied, or any remaining amount owed for services partially covered by my third-party payer/insurer. This payment will not exceed my indebtedness to the above-mentioned assignee, and I agree to pay, in a current manner. I agree to pay any costs incurred by Dr. Boisture in collecting such fees.
Signature of patient (or insured, parent or guardian)
Date

451 Andover Street, Suite 130 North Andover, MA 01845
850 Boylston street, suite 303 Chestnut hill, MA 02467
978/886-4938
________________________________________________________________________
CONSENT FOR TREATMENT
I request treatment by Jennifer Boisture, MD, for me and/or my child. I understand the treatment is a specialized service and I/my child must have a primary care doctor for standard preventative and medical care (immunizations, complete physical exams, EKG, PAP smears, etc.). I agree to see my/my child’s primary care physician for regular monitoring and preventative measures at least on a yearly basis. I understand there are general guidelines for such treatment and agree to discuss with my/my child’s primary care physician on a regular basis the need for these preventative measures. I understand it is not the responsibility of Dr. Jennifer Boisture, MD to arrange for such treatment, but agree to comply if either Dr. Boisture or my primary care physician suggests such treatment.
Dr. Boisture may employ a number of natural and pharmaceutical treatments that may not fall under the strict guidelines of conventional medicine as defined by those health care methods of diagnosis, treatment or interventions offered by most licensed physicians as generally accepted routine practice and some of the treatments may be considered complementary, integrative, alternative, nonconventional or non-standard. You have the right as a patient/parent to be informed of your/your child’s condition and the recommended conventional, integrative, complementary, alternative, non-conventional or non-standard procedure to be used so you may make an informed decision whether or not to undergo the treatment after learning of the risks involved.
I voluntarily request Dr. Jennifer Boisture and other health care providers as they may deem necessary to treat my/my child’s condition, which may include but is not limited to mood disorders, anxiety disorders, attention deficit disorder, and learning difficulties.
I understand Dr. Jennifer Boisture will direct treatment based on signs, symptoms, neuropsychological assessments (where clinically appropriate) and laboratory results. I understand it is not always possible to give a definitive diagnosis. I understand, consent and authorize that I/my child may be treated conventionally and/or with alternative, herbal and nutritional therapies, off-label use of pharmaceuticals, behavior modification, individual and group therapies and coaching. I realize just as there may be risks in continuing my/my child’s present condition with or without conventional medical treatments and procedures, there are also risks and hazards related to the performance of the alternative, integrative, complementary, non-conventional or non-standard procedures and treatments planned for me/my child.
I agree to ask about risks associated with any treatments and discuss this with Dr. Boisture before any treatment is begun and will not agree to treatment unless the risks have been explained to me to my satisfaction and I understand those risks.
I agree to comply with requests for ongoing testing to assure proper monitoring of my/my chi;d’s treatments. I agree to immediately report to Dr. Jennifer Boisture any adverse reaction or problem related to my/my child’s treatment. I understand that along with the benefits of any medical treatment or therapies, there are potential risks and complications both of treatment and not being treated. This may include worsening of current symptoms, development of new symptoms and undesirable interactions between treatments, including conventional, complementary, integrative, alternative or

“non-standard” treatments. I agree that I have received sufficient information regarding these risks and benefits, have had all my questions sufficiently answered and agree to proceed with treatment and to comply with recommended doseages. Furthermore, I have not been promised or guaranteed any specific benefit of the administration of therapies or treatment and no warranty or guarantee has been made regarding results of treatment.
I have been given an opportunity to ask questions about my/my child’s condition, conventional treatment, integrative and complementary treatment, alternative forms of treatment , risks of treatment, risks of non-treatment, procedures to be used and the risks and hazards involved, and I believe I have sufficient information to give informed consent. I certify this form has been fully explained to me, I have read it or had it read to me and I fully understand its contents. I agree not to undergo/allow my child to undergo any treatments unless I fully understand the treatment and have discussed possible risks and benefits.
I have been informed many insurance companies may not pay for some therapies, and therefore agree to be responsible for all laboratory, pharmacy, therapies and office visit charges with the full understanding
I may not be reimbursed by my insurance company. Dr. Jennifer Boisture is not responsible for an insurance company’s denial of payment.
Name of Client/Custodial Parent (please print)
Signature of Client/Custodial Parent
Date
Created 080210 Page 2 of 2 JENNIFER BOISTURE, MD, JD