Pa 100 Form PDF Details

Pa 100 form is a application for tax exemption in the state of Pennsylvania. This form is used to apply for an exemption from the payment of all or part of Pennsylvania's Personal Income Tax Act. The Pa 100 form can be used by individuals, businesses, trusts and estates. There are many eligibility requirements that must be met in order to qualify for this tax exemption so it is important to review the guidelines before submitting an application.

These are some facts you may want to analyze just before you start using the pa 100 form.

QuestionAnswer
Form NamePa 100 Form
Form Length6 pages
Fillable?Yes
Fillable fields89
Avg. time to fill out19 min 18 sec
Other namesface sheet example, blank face sheet, facesheet, patient face sheet pdf

Form Preview Example

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INTENSIVE OUTPATIENT PROGRAM

ADMISSION FACE SHEET

PATIENT LABEL

Patient Name: Last:_________________________________ First:_____________________________ Middle: ______________

Are you known by any other name? No Yes: _____________________________________________________________

Mother’s Maiden Name: ______________________________________________________________________________________

Patient Address: _____________________________________________________________________________________________

___________________________________________________________________________Zip + 4:______________ - _________

Home Phone #:____________________ Work Phone #:_____________________ Cell Phone #: _______________________

Date of Birth:____________________Age: ________________

Sex: M F Ethnicity: _________________________________________

Social Security Number: ______________________________

Marital Status: S

M

Legally Sep

Div Wid Life Partner

Occupation: _________________________________________

Religion: ____________________________________________

Employer’s Name, Address & Phone # ___________________________________________________

F/T or P/T: __________

If Student, Name & Address of School ___________________________________________________

F/T or P/T: __________

Referral Source: _____________________________________

Phone Number: _____________________________________

Emergency Contact

 

 

 

Name: ______________________________________________

Relationship: ________________________________________

Address:____________________________________________________________________________________________________

City:_____________________________________________________ State:____________

Zip Code: ______________________

Home Phone #:____________________ Work Phone #:_____________________

Cell Phone #: _______________________

Next of Kin

 

 

 

(If different than emergency contact)

 

 

 

Name: ______________________________________________

Relationship: ________________________________________

Address:____________________________________________________________________________________________________

City:_____________________________________________________ State:____________

Zip Code: ______________________

Home Phone #:____________________ Work Phone #:_____________________

Cell Phone #: _______________________

Primary Care Physician

Primary Care Physician’s Full Name: ___________________________________________________________________________

Address:_______________________________________________________________ Phone #: ___________________________

IOP-007-SR (10/08)

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BILLING INFORMATION

Primary Insurance Information

Policyholder’s Name:___________________________________________________________ Birth Date: ___________________

Policyholder’s Address: ______________________________________________________________________________________

City: ________________________________________________

State:____________ Zip + 4:________________ - __________

Policyholder’s Social Security Number: _________________

Patient’s Relationship to Policyholder: ____________________

Insurance Carrier Name: ______________________________

Phone Number: _______________________________________

Insurance Address: __________________________________________________________________________________________

Policy Number:______________________ Group Number:_____________________

Policy Effective Date: ______________

Employer Holding Insurance Policy: ________________________________________

Phone Number: ___________________

Employer’s Address: _________________________________________________________________________________________

City: ________________________________________________ State:____________ Zip Code: __________________________

Secondary Insurance Information

Policyholder’s Name:___________________________________________________________ Birth Date: ___________________

Policyholder’s Address: ______________________________________________________________________________________

City: ________________________________________________

State:____________ Zip + 4:________________ - __________

Policyholder’s Social Security Number: _________________

Patient’s Relationship to Policyholder: ____________________

Insurance Carrier Name: ______________________________

Phone Number: _______________________________________

Insurance Address: __________________________________________________________________________________________

Policy Number:______________________ Group Number:_____________________

Policy Effective Date: ______________

Employer Holding Insurance Policy: ________________________________________

Phone Number: ___________________

Employer’s Address: _________________________________________________________________________________________

City: ________________________________________________ State:____________ Zip Code: __________________________

I understand that billing my insurance company is an additional service being provided and that it is my responsibility to provide complete and accurate information to aid the billing process. It is my responsibility to keep Prince William Hospital's Center for Psychiatric and Addiction Treatment aware of any changes or modifications to my insurance coverage. Use of this billing service does not remove my responsibility for any or all charges incurred in treatment.

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__________________________________________________________________________

_______________________________________

Patient or Responsible Party Signature

Date

__________________________________________________________________________

_______________________________________

Witness Signature

Date

I have discussed the issues above with the client (and/or his or her parent/legal guardian, or other representative). My observations of this person's behavior and responses give me no reason to believe that this person is not fully competent to give informed or willing consent.

__________________________________________________________________________

_______________________________________

Staff Signature

Date

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Explanation of the Office Policies of

The Intensive Outpatient for Substance Abuse Program at Prince William Hospital

We welcome you to the The Intensive Outpatient for Substance Abuse Program at Prince William Hospital and assure you that we will provide you the best care possible. This information is intended to provide clarification and prevent future misunderstanding. The demand for Intensive Outpatient services is overwhelming. The appointment time you schedule is unavailable to many others seeking treatment.

Emergency Issues

Should you become suicidal or homicidal or require inpatient detox services, go directly to the nearest emergency room for evaluation. Make sure to give the emergency room the name and number of your Psychiatrist or Therapist. For urgent issues requiring attention of your provider, call the office to leave a message and the office staff will have the provider call at their first opportunity. Please note the days your provider is in the office.

Scheduled Evaluations

Please note your appointment time carefully. This time is being reserved for you. If you miss an evaluation without calling 48 hours in advance to cancel, you will be charged $100.00. If you miss a night of group treatment, and are a no call, no show, you will be charged $50.00. Keep in mind that insurance companies do not pay for missed appointments/missed treatment and you will be billed separately for this.

Insurance Coverage

We will be glad to help you obtain the appropriate benefit from your insurance carrier and bill your carrier as a courtesy to you. Please remember that the insurance benefits are based on a contract between you and your insurance carrier, and you are ultimately responsible for your account balance should your insurance company deny payment.

Payment for Services

Non-payment on your account can result in termination of services and referral to another provider. If your account is referred for collection you will be responsible for collection costs in the amount of 30% of your outstanding balance, together with court costs and attorney's fees.

Returned Checks

Checks that are returned to The Prince William Health System are subject to a $25 bank processing charge.

Changes

When there are changes in your insurance coverage, personal information, or medical history please notify our office on our next visit, or you may call the office to provide such information. Phone # 703-369-8409

By signing below I certify that I consent to treatment at the Intensive Outpatient for Substance Abuse Program, and have read and understand the office policies. I agree to pay the fees established by this office or my HMO managed care or insurance plan.

____________________________________________________________________

____________________________________________________________

Printed Name

Date

Signature

I have discussed the issues above with the client (and/or his or her parent/legal guardian, or other representative). My observations of this person's behavior and responses give me no reason to believe that this person is not fully competent to give informed or willing consent.

____________________________________________________________________

____________________________________________________________

Staff Signature

Date

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Intensive Outpatient Program at Prince William Hospital

Conditions of Admissions for Outpatient Service

1. Admission-Discharge

The undersigned agrees that the treatment of a patient by the Intensive Outpatient Program at Prince William Hospital clinician is a matter of clinical judgement and entirely within the discretion of the attending provider; that the Intensive Outpatient Program admits the patient with the understanding that it reserves the right, at any time, to discharge the patient for any reason that may be satisfactory to the Intensive Outpatient Program.

2. Assignment of Insurance Benefits

In the event that the undersigned is entitled to benefits of any type whatsoever arising out of any policy of insurance insuring the patient or any other party liable to the patient, said benefits are hereby assigned to Prince William Hospital for application on the patient's bill. It is agreed that Prince William Hospital may make receipt for any payment and such payment shall discharge the insurance company of any obligations under the policy to the extent of such payment, the undersigned and/or patient being responsible for such charges not covered by this agreement.

3. Financial Agreement

The undersigned agrees, whether he signs as agent or as a patient, that in consideration of the services to be rendered to the patient, he hereby individually obligates himself to pay all charges incurred by Prince William Hospital for or in connection with treatment of the patient or cost related thereto in accordance with the regular rates and terms of Prince William Hospital. Should the patient's account be referred to an attorney for collection, the undersigned shall pay reasonable attorney's fees and collection expenses. All delinquent accounts bear interest at the legal rate. The undersigned further agrees to pay the fair market value for all furniture, equipment and property that may be broken or damaged by the patient. It is understood and agreed that the undersigned are jointly and severally primarily liable hereunder and no demand or claim against the patient or the patient's estate for the amount due, and no attempt to collect therefrom, need to be made to render me/us liable hereunder.

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The undersigned authorizes that they have read the above and is the patient, or is duly authorized by the patient to execute these conditions and to accept these terms.

__________________________________________________________________________

_______________________________________

Patient Signature

Date

__________________________________________________________________________

_______________________________________

Parent/Legal Guardian Signature

Date

I have discussed the issues above with the client (and/or his or her parent/legal guardian, or other representative). My observations of this person's behavior and responses give me no reason to believe that this person is not fully competent to give informed or willing consent.

__________________________________________________________________________

_______________________________________

Staff Signature

Date

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INTENSIVE OUTPATIENT PROGRAM

As a client served in the Intensive Outpatient Program, you have specific rights. The purpose of this form is to inform you of your rights as our client.

I. Right to Voluntary Services

You have the right to request voluntary services.

You have a right to

have a staff person assigned specifically to work with you in resolving your problems and ensuring that your service is properly provided

a personal, individualized assessment of your needs

an individualized service plan, which will be reviewed regularly, developed with your input, and implemented with your consent

services beginning within a reasonable time and ending when they are no longer needed or effective

another opinion regarding services provided (However, seeing someone outside of this setting is done at your own expense)

referrals to other competent professionals and sources of help as indicated by your service plan

terminate service if your circumstances require it or you feel it is in your best interest, unless doing so puts you or others in grave danger

resume services following termination

file a grievance if you feel your rights have been denied or violated. The Behavioral Medicine contact for filing a grievance is David Carlini at (703) 369-8883. The Regional Human Rights Advocate at (877)600-7431 is available as well to discuss Human Rights Violation issues.

II.Right to Refuse Services You have a right to

refuse any form of service or treatment unless it has been ordered by the court or in emergency situations when necessary to prevent harm to yourself and others (If you must receive services not by your own choice, you have the right to a lawyer, a court hearing, and an appeal of the decision to a higher court. If you cannot afford a lawyer,the court will appoint one for you.)

refuse service with your primary clinician and request another practitioner in this setting or a referral to another setting

be informed that without services, your situation may get worse

refuse to be filmed or audiotaped without your written permission

refuse to take part in research studies without your written permission.

III. Right to Confidentiality / Privacy

All information about you is understood to be confidential to protect your privacy. This information includes the fact that you have or have not received services. All professionals and other staff associated with this setting are obligated to preserve your privacy to the extent permitted by law.

You have the right to

determine the amount of information to be released, whether to or from anyone outside this setting, by signing a consent form

sign a consent form to release information that is specific to each situation when information is to be released(You will not be asked to sign a "blanket" consent for release of information.)

determine the length of time that information may be released and cancel your permission at any time

(However, information may be released without your permission in a medical emergency to save lives, to prevent injury to yourself or others, or when required by law or ordered by the court.)

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IV. Right to a Humane Mental and Physical Environment

You have a right to

courtesy, respect, and professionalism from everyone involved in your service in this setting

facilities that are comfortable and safe, promote dignity, ensure privacy, and contribute to positive outcomes of your service.

V. Right to Information

You have a right to verbal and written information about

your rights, role, and responsibilities as a client in this setting

your primary clinician's rights, role, and responsibilities in this setting

what you can expect during your service process-appointment, cost, handling of emergencies, and other practices and procedures of this setting as they affect you

your primary clinician's credentials and professional code of ethics

means to contact your primary clinician in both emergency and non-emergency situations

the name of and means to contact your primary clinician's supervisor

procedure for reviewing your clinical records.

VI. Rights Pertaining to Medication

You have a right to

the administration of medication only under the written order of a physician

a complete explanation, in language you can understand, of the purpose of any medication, possible side effects, and possible results of long-term use

full consideration of your opinions and reactions to the medications

a regular review of your medication for the purpose of adjustment, as a check for possible side effects, and for possible reduction or elimination

have accurate records kept noting your medication history, including any adverse reactions or drug allergies

have medication prescribed for you only when necessary.

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__________________________________________________________________________

_______________________________________

Patient Signature

Date

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Step 1: Select the button "Get Form Here" on this website and next, click it.

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For each part, complete the information required by the platform.

entering details in facesheet part 1

Write the essential information in the Address, CityStateZipCode, HomePhoneWorkPhoneCellPhone, NextofKin, Ifdifferentthanemergencycontact, Name, Relationship, Address, CityStateZipCode, HomePhoneWorkPhoneCellPhone, PrimaryCarePhysician, PrimaryCarePhysiciansFullName, and AddressPhone segment.

facesheet Address, CityStateZipCode, HomePhoneWorkPhoneCellPhone, NextofKin, Ifdifferentthanemergencycontact, Name, Relationship, Address, CityStateZipCode, HomePhoneWorkPhoneCellPhone, PrimaryCarePhysician, PrimaryCarePhysiciansFullName, and AddressPhone blanks to fill

It's essential to record some details within the area .

facesheet  fields to fill out

The Hole, ctoc, PrimaryInsuranceInformation, PolicyholdersNameBirthDate, PolicyholdersAddress, CityStateZip, InsuranceCarrierNamePhoneNumber, InsuranceAddress, EmployersAddress, CityStateZipCode, SecondaryInsuranceInformation, PolicyholdersNameBirthDate, PolicyholdersAddress, and CityStateZip segment enables you to point out the rights and obligations of both sides.

facesheet Hole, ctoc, PrimaryInsuranceInformation, PolicyholdersNameBirthDate, PolicyholdersAddress, CityStateZip, InsuranceCarrierNamePhoneNumber, InsuranceAddress, EmployersAddress, CityStateZipCode, SecondaryInsuranceInformation, PolicyholdersNameBirthDate, PolicyholdersAddress, and CityStateZip blanks to fill out

Look at the fields CityStateZip, InsuranceCarrierNamePhoneNumber, InsuranceAddress, EmployersAddress, CityStateZipCode, PatientorResponsiblePartySignature, Date, WitnessSignature, and Date and thereafter fill them in.

Completing facesheet step 5

Step 3: Press "Done". Now you can transfer the PDF document.

Step 4: In order to avoid possible upcoming challenges, please be sure to obtain a minimum of two or three duplicates of each form.

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