Please download and print the
New Patient Intake Form, and the
Physician-Patient Contract.
Please fill out the forms in their entirety and bring the completed documents to your initial evaluation. You may need to download and install Adobe's free
Acrobat Reader to open these documents.
The document,
Questions To Ask Your Insurance Company, is very important for those patients who want to use their private health insurance to help offset part of the costs of their mental health services.
If you are already in treatment with another mental health provider, you will also need to download and print the
Consent For Release Of Information and bring this to your initial evaluation. Be sure to fill out the name of your therapist and his/her contact information at the top of the Consent form.
Matthew R. Mills, M.D. is a panel provider for Blue Cross / Blue Shield PPO of Illinois. Please bear in mind that patients will be held fully responsible for all non-remibursed costs from your insurance carrier. These costs include denied claims, co-payments and fees for late cancellation of your appointments. If you choose to use your BC/BS PPO plan, I will ask that you provide your credit card number (or advance payment) to secure my services. Co-payments are due at the beginning of each visit (cash, check, VISA/MC).
If your insurance has denied a claim for a visit, or if they have delayed reimbursement for a period greater than 90 days, you are responsible for the full cost of the visit. Dr. Mills will notify you in cases of denial or delayed reimbursement. You are welcome (and strongly encouraged) to contact your insurance company if there is a denial, or a delay in processing a claim.
If you have a insurance plan other than BC/BS PPO, you can still use your health benefits! However, in this instance, Matthew R. Mills, M.D. is considered an 'out-of-network provider.' I will provide you with a billing receipt with all the information you will need to submit the claim on your own to your insurance company. Please review the section entitled 'Insurance Reimbursement' on page five (5) of the
Physician-Patient Contract for more information.
Self-pay patients (i.e., patients not using any form of health insurance), are most welcome! My professional fees for self-pay patients are clearly outlined in the Physician-Patient Contract.
You may also download these documents as a single
WinZip Archive.