Patient Forms
TOCDOC, PO Box 702, Savoy, IL 61874, Phone: 815-6836109, Email:
Email address *
Patient HIPAA Acknowledgement Form
Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.
To comply with one of HIPAA’s requirements, we are giving you a copy of our Notice of Privacy Practices. This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices.
Do you acknowledge? *
I understand that I am consenting and agreeing only to those services that the above-named provider is qualified to provide within: (1) the scope of the provider’s license, certification, and training; or (2) the scope of license, certification, and training of the behavioral health care providers directly supervising the services received by the patient.
If the patient is under the age of eighteen or unable to consent to treatment, I attest that I have legal custody of this individual and am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual.
By signing below, you certify that you have been informed and understand the terms stated in the Treatment Consent Form. You indicate that you understand the scope of my services, session structure, fees, cancellation/no-show policies, payment policy, insurance reimbursement, confidentiality, sharing of information, the nature of my practice, and my contact information, and that you agree to abide by the terms stated above during the course of our therapeutic relationship.
I understand that I have the right to receive a copy of this consent and right to withdraw this consent at any time via a written request.
Do you agree and consent? *
Patient Consent for Use and Disclosure of Protected Health Information
I hereby give my consent for The Oval Circle, LLC to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO).
(The Notice of Privacy Practices provided by The Oval Circle, LLC describes such uses and disclosures more completely.)
I have the right to review the Notice of Privacy Practices prior to signing this consent.
The Oval Circle, LLC reserves the right to revise its Notice of Privacy Practices
at any time. A revised Notice of Privacy Practices may be obtained by forwarding a
written request to Dr. Nitin Bhosale, 701 Devonshire Drive, Suite B1, Champaign, IL 61820
With this consent, The Oval Circle, LLC may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, The Oval Circle, LLC may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”
With this consent, The Oval Circle, LLC] may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that The Oval Circle, LLC restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, The Oval Circle, LLC may decline to provide treatment to me.
Do you consent? *
Patient Financial Responsibility
I understand I am responsible for fees incurred at the time of service at TOCDOC (The Oval Circle, LLC).
For your convenience, we offer several payment options, including point-of-sale (POS) and online payment services. We take personal checks as well as all major credit cards. We will provide you with an invoice, at your request.
If I fail to pay any outstanding fees or charges, I understand that my balance may be turned over to a collection agency and/or my debt may be reported to the credit bureau if the bill is not paid within 90 days of last date of service.

Cancellation / No Show Policy:

We understand there may be times when you miss an appointment due to emergencies or obligations to work or family. However, we urge you to call 24-hours prior to canceling your appointment. I understand that if I cancel within less than 24 hours of notice of my appointment time or I do not show up, TOCDCOC (The Oval Circle, LLC) has the right to issue a cancellation fee up to the full cost of the scheduled appointment.
I understand if I no show for two consecutive appointments, no show for three appointments or cancel for a total of four appointments, I may be discharged from care.
The Practice will notify you in writing, via certified mail, if you are discharged from care.

Do you agree? *
Patient name *
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