PATIENT INFORMATION SUMMARY
PERSONAL INFORMATION
Name___________________________________Age__________Birthdate________________
Social Security Number_________________________________________________________
Address______________________________________________________________________
Town/City___________________________State_______________Zip___________________
Phone(___)________________o.k. to leave messages Y/N work/cell___________________Y/N
Place of employment____________________________________________________________
E-mail address ______________________________________________________
Please circle your preferred Reminder Method: E-mail or Phone Message
Emergency Contact _________________________Phone: (___)____________________
INSURANCE INFORMATION
Insurance Company____________________________________Preauthorization needed Y/N
Policy Number_______________Group number________________Copay$_________________
If you are not the policy holder, please complete the following:
Name of policy holder_______________________________ Phone (___)___________________
Address of policy holder:_________________________________________
City_____________________State_________Zip________________
Birthdate of policy holder_________________Relationship to policy holder_________________
Employer______________________________________________________________________
*Do we have permission to discuss financial matters with the above named person Y/N
RESPONSIBLE PARTY (If other than yourself, please indicate below)
Name________________________________ Relationship________
Address________________________Town_____________________State______Zip_________
Phone number ( )_________________________________
MEDICAL AND PSYCHIATRIC INFORMATION
Referred by_____________________________Current therapist__________________________
Current primary care physician_____________________________________________________
I certify that the above information is correct, and I consent to the release of
information necessary to process the insurance claims. I understand you will
release the information only to the insurance companies listed above.
PLEASE NOTIFY OF INSURANCE CHANGES IMMEDIATELY
Billing Policies for Psychiatric Associates
Please read carefully and sign below:
Please contact your insurance company to verify whether preauthorization is needed for mental
health visits. Many insurance companies require authorization for mental health services even if
authorization is not required for other medical services.
Payment from your insurance
company could be reduced or denied if authorization is not obtained.
There may be
instances your insurance company deems certain services as not “medically necessary” or
“investigational”. Please be aware while we will make every effort to obtain insurance
reimbursement for your treatment, reimbursement is never guaranteed, which may leave the
patient solely responsible for the full cost of treatment.
For your convenience we will submit the claim for your visit to your insurance company. We
request that you pay your portion of the charges (copay) at the time of service. Please remember
the insurance contract is between you and your insurance carrier. Questions about their payment
and/or coverage should be directed to them. Our office cannot guarantee insurance coverage for
services provided.
In the event of a delay or denial of your claim, you are responsible for payment in full in a timely
manner. If payment cannot be made when due, please contact our Practice Administrator to set
up an extended payment arrangement. After 90days, if no payments have been received or
arrangements made, necessary collection proceedings will begin. You will be responsible for all
costs, including court costs and attorney fees, incurred in the collection of these charges.
Please note that we request 24 hours notice prior to canceling an appointment
.
If less than
24 hours notice is given, you may be billed $25.00. The charge for missing an appointment
without notification is $95.00. A $25.00 fee will be assessed for the completion of medical
forms.
These include but are not limited to: bulletins, work excuses/releases, disability forms,
FMLA forms, academic withdrawal and tuition reimbursement forms, etc. Insurance companies
will not pay for these charges and you will be responsible for payment in full. **
Initials: ______
When you sign this agreement you are responsible for payment of your bill. If you wish to
arrange for someone else to have responsibility for some or your entire bill, you must arrange for
them to sign a copy of this agreement. Until such a copy is on file, we must hold you responsible
for the bill.
I have read the above information and agree to accept responsibility for payment.
_________________________________
_____________________
Signature
Date
_________________________________
_____________________
Revised 8/26/2015
Consent for Purposes of Treatment, Payment and Healthcare Operations
I consent to the use or disclosure of my protected health information by Psychiatric Associates for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Psychiatric Associates. I understand that diagnosis or treatment of me by Todd VerHoef, MD, Dana Weibel, MD, Kimberly VerHoef, MD, Christopher Welsh, MD, Ann M. Glick, MSN, ARNP, FPMHNP, Barbara O’Rourke, RN, PhD, LMHC, Lisa Kim, MA, LISW, Erica Lutz RN, CRC, LMHC, Aileen Barnhouse, RN, LMHC, CRC, Sally Henderson, PhD, LMFT, Penny Clark MA, LMHC, ATR, Tina Issa, LMHC, CRC, CADC, Judith Earley PhD, LMFT, Jennifer Sacora, LMHC, MA, Joy Ashbaugh LMHC, Cynthia Vaske LISW, CEAP, CPC, may be conditioned upon my consent as evidenced by my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Psychiatric Associatesis not required to agree to the restrictions that I may request. However, if Psychiatric Associates agrees to a restriction that I request, the restriction is binding on
Psychiatric Associates and
Todd VerHoef, MD, Dana Weibel, MD, Kimberly VerHoef, MD, Christopher
Welsh, MD, Ann M. Glick, MSN, ARNP, FPMHNP, Barbara O’Rourke, RN, PhD, LMHC, Lisa Kim, MA, LISW, Erica Lutz RN, CRC, LMHC, Aileen Barnhouse, RN, LMHC, CRC, Sally Henderson, PhD, LMFT, Penny Clark MA, LMHC, ATR, Tina Issa, LMHC, CRC, CADC, Judith Earley PhD, LMFT, Jennifer Sacora, LMHC, MA, Joy Ashbaugh LMHC, Cynthia Vaske LISW, CEAP, CPC .I have the right to revoke this consent, in writing, at any time, except to the extent that Todd VerHoef, MD, Dana Weibel, MD, Kimberly VerHoef, MD, Christopher Welsh, MD, Ann M. Glick, MSN, ARNP, FPMHNP, Barbara O’Rourke, RN, PhD, LMHC, Lisa Kim, MA, LISW, Erica Lutz RN, CRC, LMHC, Aileen Barnhouse, RN, LMHC, CRC, Sally Henderson, PhD, LMFT, Penny Clark MA, LMHC, ATR, Tina Issa, LMHC, CRC, CADC, Judith Earley PhD, LMFT, Jennifer Sacora, LMHC, MA, Joy Ashbaugh LMHC, Cynthia Vaske LISW, CEAP, CPC, or Psychiatric Associates has taken action in reliance on this consent.
My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I understand I have a right to review Psychiatric Associates Notice of Privacy Practices prior to signing this document. The Psychiatric Associates Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the Psychiatric Associates. The Notice of Privacy Practices for Psychiatric Associates is also provided in the waiting room of Psychiatric Associates. This Notice of Privacy Practices also describes my rights and Psychiatric Associates duties with respect to my protected health information.
Psychiatric Associates reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
Signature of Patient or Personal Representative ______________________________________ Name of Patient or Personal Representative
Patient Record of Disclosures
I wish to be contacted in the following manner (check all that apply):
□ Home Telephone (___)___________________
□ Written communication
□
O.K. to leave message with detailed information□
O.K. to mail to my home address□
Leave message with call-back number only□
O.K. to mail to my work/office address
□
O.K. to fax to this number (___)__________□ Work Telephone (___)____________________ □ Cell Telephone (___)___________________
□O.K. to leave message with detailed information
□
O.K. to leave message with detailed information□
Leave message with call-back number only□
Leave message with call-back number only□ Other _____________________________________________________________________________________ Patient/Guardian Signature______________________________________ Date _______________________ Print Name of Patient __________________________________ Patient D.O.B ______________________
FOR OFFICE USE ONLY:
Record of Disclosures of Protected Health Information
Date Disclosed to Whom Address or Fax Number
(1) Description of Disclosure/Purpose
of Disclosure
By Whom Disclosed (2) (3)
(1) Check this box if the disclosure is authorized
(2) Type key: T= Treatment Records: P= Payment Information : O= Healthcare Operations
(3) Enter how disclosure was made: F=Fax; P=Phone; E= Email; M=Mail; O=Other
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individuals is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.
The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual. Healthcare entities must keep records of PHI disclosures. Information provided below, if completed properly, will constitute an adequate record.
New Patient Questionnaire
Name: ______________________________
Date of Birth: ________________________
Today’s Date: ________________________
What are you seeking help with?
_____________________________________________________________________
__________________________________________________________________________________________________
List any medication allergies that you have.
_________________________________________________________________List all the medications you are taking. Include over the counter medications, vitamins, and supplements.
1.
___________________________
2.
___________________________
3.
___________________________
4.
___________________________
5.
___________________________
6.
___________________________
7.
___________________________
8.
___________________________
9.
___________________________
10.
___________________________
11.
___________________________
12.
___________________________
List any previous medications trials for mental health symptoms.
__________________________________________
__________________________________________________________________________________________________
Which pharmacy do you use?
________________________________________________________________________
Have you ever had any of these illnesses?
☐ Cancer Type: ________________ ☐ Heart attack
☐ Artery disease ☐ Heart arrhythmia ☐ High blood pressure ☐ High cholesterol ☐ Stroke ☐ Diabetes ☐ Liver disease ☐ Ulcers ☐ Heartburn or reflux ☐ Seizures ☐ Asthma ☐ Emphysema
☐ Obstructive sleep apnea ☐ Arthritis ☐ Allergies ☐ Kidney disease ☐ Anemia ☐ Glaucoma ☐ Thyroid disease ☐ Head injury
☐ Sexually transmitted diseases ☐ Headaches or migraines ☐ Fibromyalgia
☐ Restless leg syndrome ☐ Chronic back pain
☐ Other _______________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________
List any surgeries that you have had.
_____________________________________________________________________ ____________________________________________________________________________________________________________Has anyone in your family had any of the following illnesses? If so, list their relationship to you?
☐ Depression ____________________
☐ Bipolar Disorder ____________________
☐ Anxiety ____________________
☐ Panic Disorder ____________________ ☐ Post-Traumatic Stress Disorder ____________________ ☐ Obsessive Compulsive Disorder ____________________
☐ ADD or ADHD ____________________
☐ Eating Disorder ____________________ ☐ Borderline Personality Disorder ____________________
☐ Alcohol Abuse or Dependence ____________________ ☐ Drug Abuse or Dependence ____________________ ☐ Dementia or Alzheimer’s Disease ____________________
☐ Suicide ____________________
☐ Unexplained Sudden Death ____________________ List any other mental illness in your family
☐ ____________________ ____________________ ☐ ____________________ ____________________ ☐ ____________________ ____________________
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Social History
Are you in a relationship? ☐ Yes ☐ No If yes, with a ☐Male ☐Female Are you? ☐Married ☐Divorced ☐Widowed Are you sexually active? ☐ Yes ☐ No
Do you have any children? ☐ Yes ☐ No If yes, list their names and ages. Name: ____________________________ Age: _____ Name: ____________________________ Age: _____ Name: ____________________________ Age: _____ Name: ____________________________ Age: _____ Name: ____________________________ Age: _____ Name: ____________________________ Age: _____ Are you employed? ☐ Yes ☐ No Current Occupation ____________________________________________________________ Are you a student? ☐ Yes ☐ No If so, where? __________________________________________________________________ How far did you go in school? __________________________________________________________________________________ Have you served in the military? ☐ Yes ☐ No If yes, describe service? ______________________________________________ Do you smoke or chew tobacco? ☐ Yes ☐ No If yes, how much per day? ____________________________________________ Do you drink alcohol? ☐ Yes ☐ No If yes, ☐Occasionally ☐1 drink/day ☐2-3/day ☐4+/day
Do you use any recreational drugs? ☐ Yes ☐ No If yes, list the drugs ________________________________________________
Do you currently have any of the following problems?
Yes
No
Yes
No
General Constitutional
Recent weight loss ☐ ☐
Recent weight gain ☐ ☐
Fatigue ☐ ☐
Fever ☐ ☐
Eyes
Vision changes ☐ ☐
Eye pain ☐ ☐
Ears, nose, mouth and throat
Runny nose ☐ ☐ Ringing in ears ☐ ☐ Sore throat ☐ ☐ Hearing loss ☐ ☐ Dry mouth ☐ ☐ Cardiovascular Chest pain ☐ ☐ Dizziness/faintness ☐ ☐ Loss of consciousness ☐ ☐ Respiratory Cough ☐ ☐ Wheeze ☐ ☐ Shortness of breath ☐ ☐ Gastrointestinal Abdominal pain ☐ ☐ Nausea/vomiting ☐ ☐ Diarrhea ☐ ☐ Constipation ☐ ☐ Blood in stool ☐ ☐ Genitourinary Painful urination ☐ ☐ Loss of libido ☐ ☐ Males Erectile dysfunction ☐ ☐ Females Pregnant ☐ ☐ Nursing ☐ ☐ Change in periods ☐ ☐ Hot flashes ☐ ☐ Menopause ☐ ☐ Musculoskeletal Joint pain ☐ ☐ Stiffness ☐ ☐ Skin Rash ☐ ☐ Neurological Seizures ☐ ☐ Headache ☐ ☐ Numbness ☐ ☐ Limb weakness ☐ ☐ Poor balance ☐ ☐ Endocrine Tremor ☐ ☐ Excess sweating ☐ ☐ Thin hair ☐ ☐ Dry skin ☐ ☐ Excess thirst ☐ ☐ Excess hunger ☐ ☐ Frequent urination ☐ ☐ Hematologic Excess bleeding ☐ ☐ Easy bruising ☐ ☐ Allergic/immunologic Sneezing ☐ ☐ Itching ☐ ☐ Hives ☐ ☐
For Office Use
I have reviewed this information. Pertinent positives and negatives are documented in my note from today’s visit.
M.D./ ARNP Signature __________________________ Date _______________
