PATIENT INFORMATION
I. IDENTIFYING INFORMATION DATE: ______________________
Name: _______________________________ Date of Birth: __________________ Age: ______ Street:____________________________________________________________________________ City: _______________________ State: ________ Zip: ___________ Email: _________________ Phones: Home _____________________ Work ___________________ Cell ___________________ Occupation / Grade in school: ________________________ Place of Employment / School: _______________ Can we leave a message on your cell, home, or work voice mail? YES NO (circle one)
___________________________________________________________________________________
II. REFERRAL INFO: How did you find out about Dr. Hull / A New Start Medical Center?
__________________________________________________________________________________ May we send a thank you to the referral source? ________Yes ________ No
______________________________________________________________________ III. BILLING INFORMATION
Person responsible for bill:__________________________ Relationship to patient: _______________
Insurance Company:_________________________________________________________________ (We request this information in case it is necessary to obtain prior authorization for a prescribed medication)
IV. FAMILY Marital Status (circle one): single / engaged / married / divorced / girlfriend / boyfriend Spouse name: ________________________________
Mother name (if minor):_________________________ Father name:_____________________________ Name / ages of children or siblings:________________________________________________________
I have read and understand the Important Information for Patients of A New Start Medical Center. I have also read and understand the disclosure (HIPPA) information.
V. CLINICAL CONCERNS - Briefly describe what prompted you to seek care from Dr. Hull at this time. Problem Areas: In the following list, place a check mark next to each item that identifies an area of concern to you (place two checks by those items that are most important)
____ Stress ____ Thoughts of Suicide ____ Anger/ Temper ____ Sexual Concerns ____ Depression ____ Rape
____ Education/School Work ____ Incest
____ Family Problems ____ Trouble making decisions ____ Fearfulness ____ Unhappy most of the time ____ Marital Problems ____ Use of alcohol
____ Physical Problems ____ Use of drugs ____ Problem with children ____ Worry ____ Religious/ Spiritual Concerns ____ Work
____ Problems with Social Relationships ____ Other: Specify ________________________ Is there anything else that you believe might be important for Dr. Hull to know at this time?
_________________________________________________________________________________ In the past, have you ever been the victim of or witnessed any type of traumatic incident? If yes, please explain: _____________________________________________________________________________ Previous mental health counseling? YES / NO (circle one)
Who/When/Where? ____________________________________________________ Previous Psychiatrist? YES / NO (circle one)
Who/When/Where? ____________________________________________________ Describe any physical (medical) problems you have that require medication or physical care:
_________________________________________________________________________________ Medication(s) currently using:
__________________________________________________________________________________
__________________________________________________________________________________
Recent changes or stressful circumstances (circle yes or no for each one):
1. Have there been any recent deaths in the family? yes / no
2. Has there been a significant changes in your primary relationship (eg: parent, girlfriend, boyfriend, spouse) or have you had a disruption in an important friendship or other relationship? yes / no
3. Have any new children been adopted or born or come to live with the family? yes / no
4. Have you recently moved? yes / no
5. Have you (or a child) recently left home? yes / no
6. Have you had a change in your religious or spiritual community or affiliation? yes / no
7. Have you or a family member been seriously ill or hospitalized? yes / no
8. Have you or a close family member had a recent legal problem or been in prison? yes / no
9. Has a family member had emotional, mental health, or substance abuse problems? yes / no
10. Have you been under stress from too many activities or responsibilities? yes / no
11. Have there been a lot of arguments or conflicts at home? yes / no
12. Have you recently started an academic program or dropped out or graduated? yes / no
13. Have you had a change in employment (job change, job loss, promotion, retirement)? yes / no
14. Have you recently had a change in financial status or increase in financial stress? yes / no
15. Have you witnessed verbal, emotional, physical or sexual abuse; threatening or disturbing behavior; or a scary situation (such as a car accident or crime)? yes / no
16. Have you personally experienced verbal threats, threatening behavior, physical violence, sexual assault or a scary situation (such as a car accident or crime)? yes / no
If you answered “Yes” to any of the questions please explain briefly:
___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ How do you typically respond to problems or stress? (check all that apply)
⏯ Sleep a lot ⏯ Fight with family/friends ⏯ Exercise more
⏯ Have trouble sleeping ⏯ Ask for help ⏯ Withdraw
⏯ Get moody or sensitive ⏯ Ignore the problem ⏯ Take it out on others
⏯ Discuss it with someone ⏯ Try to solve the problem ⏯ Eat more / less than usual
⏯ Lose patience more ⏯ Blame others ⏯ Pray
⏯ Ask for comfort ⏯ Focus on caring for others ⏯ Focus on hobby / activity
⏯ Use Alcohol ⏯ Have physical symptoms ⏯ Cry a lot
⏯ Use Drugs ⏯ Get bossy or controlling ⏯ Lose patience more
⏯ Watch a lot of TV ⏯ Tell others about situation ⏯ Re-focus on spirituality
⏯ Give up / give in ⏯ Avoid thinking about it ⏯ Vent anger / blow off steam
⏯ Stay busy ⏯ Work more ⏯ Increase computer time
Adolescent Questionnaire
(skip this page if you are under 10 years of or over 21 years old)
1. Most of all I want _____________________________________________________________ 2. I’m different from others because_________________________________________________ 3. People are always_____________________________________________________________ 4. It would be funny if____________________________________________________________ 5. Girls think I__________________________________________________________________ 6. Boys think I__________________________________________________________________ 7. My family____________________________________________________________________ 8. I worry about_________________________________________________________________ 9. I wish I could stop_____________________________________________________________ 10. When I grow up_______________________________________________________________ 11. I just can’t____________________________________________________________________ 12. People shouldn’t_______________________________________________________________ 13. I want to know________________________________________________________________ 14. It hurts when__________________________________________________________________ 15. If I were a boy/girl_____________________________________________________________ 16. All my life I__________________________________________________________________ 17. My father thinks I______________________________________________________________ 18. I get mad when________________________________________________________________ 19. When I get mad, I______________________________________________________________ 20. If I were older_________________________________________________________________ 21. If I were younger______________________________________________________________ 22. I’m afraid of__________________________________________________________________ 23. When I’m afraid, I_____________________________________________________________ 24. I often wonder_________________________________________________________________ 25. Other children_________________________________________________________________ 26. Nobody knows________________________________________________________________
115 Habersham Drive, Fayetteville, Georgia 30214 Phone: 678-788-7500 Fax: 678-788-7500
Primary Care Communication Form
Patient’s Name: __________________________________ Date of Birth: _________________ Primary Care Provider (PCP): _________________________________________
PCP Phone #: _______________________ PCP Fax #: __________________________
PCP Address: __________________________________________________________________ I give permission for Dr. Hull to contact my Primary Care Physician and share protected health care information.
_______________________________________ ____________________________________ Patient Signature Date
(This Section For Physician Use Only)
Dear Dr: ___________________________________________
The above patient is receiving medical psychiatric services at my office. The patient has given permission for you and I to communicate with each other, and I hope that you find the following information helpful in coordinating care.
Date of initial evaluation: _____________________
DSM-V Diagnosis: Axis I: _____________________________________________________ Axis II: _____________________________________________________ Axis III: _____________________________________________________ Axis IV:______________________________________________________ Other Considerations: ___________________________________________ Treatment Plan: Medications:_____________________________________________________________ Counseling:_____________________________________________________________ Other: _________________________________________
Please feel free to call me if you so desire to discuss this case.
Clinician Name: _______________________ Signature: __________________ Date: _______
Patient’s Consent
I consent for my clinician to disclose my protected health information (PHI) as required by my insurance company. Furthermore, if my insurance company requires coordination of care with my Primary Care Provider (PCP), I consent for my clinician to disclose my protected health information to my PCP. I have read A New Start Medical Center, Inc.’s Policies and Practices to Protect the Privacy of Your Health Information, and I both understand and approve of its content.
Financial Responsibility
A New Start Medical Center, Inc. will assist you by providing the information necessary for you
to submit to the insurance company, should you choose to do so. However, you maintain full responsibility for paying all charges for services rendered. Medicare patients may not submit to Medicare for reimbursement for services provided by A New Start Medical Center and have read and signed the Medicare waiver form. Payment is to be made at the time that services are
rendered. A New Start Medical Center, Inc. does accept payment by cash, check, Visa,
MasterCard, and Discover. The fee for an initial appointment is $250 and all follow up visits are $100. Dr. Hull reserves the right to charge his hourly rate of $300 per hour under the following circumstances: returning phone calls to patients and their attorneys, completing affidavits, and writing letters on behalf of clients.
Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on January 01, 2014. We reserve the right to change the terms of this notice and to make the new notice provisions effective in all PHI that we maintain. We will provide you with a revised notice by mail or during your next session.
Cancellation Policy
In the event of a true emergency, you will not be charged for an appointment cancellation. Cancellations for any other reason that are not received by the center’s staff at least 24 hours prior to the scheduled appointment will be billed at $100. Monday appointments need to be cancelled by noon on Friday. To cancel an appointment scheduled on the day after a holiday, it needs to be cancelled on the day prior to the holiday.
_________________________________ __________________________________ Printed Name of Patient Witness
_________________________________ __________________________________ Signature of Patient (or Guardian) Date
Notice of A New Start Medical Center’s Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW MENTAL HEALTH AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS
TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations.
We may use or disclose your protected health information (PHI), for treatment, payment, and
health care operations purposes with your consent. To help clarify these terms, here are some
definitions:
· “PHI” refers to information in your health record that could identify you. · “Treatment, Payment and Health Care Operations”
-Treatment is when we provide, coordinate or manage your health care and other related
services. An example of treatment would be when we consult with another health care provider, such as your family physician or another clinician. Another example would be when we release your treatment plan to your insurance company and/or to your primary care physician.
-Payment is when reimbursement is provided to you by your insurer for your healthcare.
Examples of payment are when we disclose your PHI to your health insurer to assist you in receiving reimbursement for your health care or to determine eligibility or coverage.
-Health Care Operations are activities that relate to the performance and operation of my
practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
· “Use” applies only to activities within our [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· “Disclosure” applies to activities outside of our [office, clinic, practice group, etc.] such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we asked for information for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your Medical Psychiatric Notes.
“Medical Psychiatric Notes” are notes we have made about your conversation during a private,
group, joint, or family session, which we have kept separate from the rest of your medical records. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI or Medical Psychiatric Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
We may use or disclose PHI without your consent or authorization under the following circumstances:
· Child Abuse – If we have reasonable cause to believe that a child has been abused, we must report that belief to the appropriate authority.
· Adult and Domestic Abuse – If we have reasonable cause to believe that a disabled adult or elderly person has had a physical injury or injuries, inflicted upon them other than by
accidental means, or has been neglected or exploited, then we must report that belief to the appropriate authority.
· Health Oversight Activities – If we are the subject of an inquiry by the Georgia Board of Medical Examiners, we may be required to disclose protected health information regarding you in proceedings before the Board.
· Judicial and Administrative Proceedings - If you are involved in a court proceeding and a request is made about the professional services we provided you or the records thereof, such information is privileged under state law, and we will not release information without your written consent or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
· Serious Threat to Health of Safety – If we determine, or pursuant to the standards of my profession should determine, that you present a serious danger of violence to yourself or another we may disclose information in order to provide protection against such danger for you or the intended victim.
· Worker’s Compensation – We may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
IV. Patient’s Rights and Clinician’s Duties
Patient’s Rights:
· Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you request.
· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations (for example, you may not want a family member to know that you are seeing clinicians. On your request, we will send your bills to another address).
· Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in your mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviews. On your request, we will discuss with you the details of the request and denial process. Your clinician may also deny access to your
Medical Psychiatric Notes.
· Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.
· Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, we will discuss with you the details of the accounting process.
· Right to a Paper Copy – You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically.
Clinician’s Duties:
· We are required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
· We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.
· If we revise the policies and procedures, we will notify you by mail or during your next visit.
V. Complaints
If you are concerned that your clinician has violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact Dr. Barry Hull at A New Start
Medical Center, Inc. You may also send a written complaint to the Secretary of the U.S.
Department of Health and Human Services. Dr. Hull can provide you with the appropriate address upon request.
VI. Cancellation Policy
In the event of an emergency, you will not be charged for session cancellation. Cancellation for any other reason that is not received by the center’s staff at least 24 hours prior to the scheduled appointment will be billed at $100. Monday appointments need to be cancelled by noon on Friday. To cancel an appointment scheduled on the day after a holiday, it needs to be cancelled on the day prior to the holiday. Your insurance company will not pay for missed appointments.
Important Information for Patients of A New Start Medical Center, Inc. (ANSMC) Is Dr. Hull a Psychiatrist? - Dr. Hull is a Board Certified Family Medicine specialist and a Diplomat of the American Board of Family Medicine (Boarded by The American Board of Family Medicine in 1991, 1997, and 2004). He is also Board Certified in Clinical Lipidology by The American Board of Clinical Lipidology (2005) and a Diplomat of the American Board of Clinical Lipidology. He completed his Certification as a Master Clinician in
Psychopharmacology in 2005 (awarded by the Neuroscience Education Institute). He is authorized to provide medical psychiatric services to patients in addition to traditional non-psychiatric medical services. He is not a board certified psychiatrist as he did not complete a residency program in psychiatry (therefore he is not eligible to sit for the psychiatry boards); however, he has well over twenty years of practice experience including extensive experience managing patients’ mental health issues with medications. If for any reason he does not feel competent or qualified to manage your mental health problem then he will appropriately refer you to a practicing psychiatrist (just as he would refer you to a subspecialist for your physical health needs if he felt inadequately qualified to manage such a problem).
Does Dr. Hull accept or file insurance? – Dr. Hull does not accept any insurance and is not on any insurance panels (including Medicare and Medicaid). You are given a “superbill” with the necessary codes to file for out-of-network reimbursement (you may NOT file for reimbursement with Medicare or Medicaid). Often patients do get some reimbursement; more often their charges are applied to their deductible (which is a helpful thing for you).
Does Dr. Hull do “counseling” or “therapy?” – Dr. Hull has very little formal training in counseling or therapy. His focus is on diagnostic evaluation and medication management. He does talk to his patients and renders advice; however, he does not do formal psychotherapy. He will recommend therapy for patients if he feels that it is necessary (which is usually the case), and he does make appropriate referrals in that regard (to therapists both within and outside of A New Start Counseling Center).
Running on time: Dr. Hull devotes one hour of time for a new patient appointment and up to twenty minutes for a follow-up visit. Please arrive to your appointment on time as failure to do so will reduce the amount of time available for your appointment (i.e.: if you are late for your appointment then your appointment will be shortened). If you feel that you need more time then please let us know (however, we will charge double for two appointment slots).
Medication Refills: Please make certain before you leave that you have enough refills on all of your prescription medication(s) managed through this office to last until your next scheduled visit. Calls for refills are time-consuming for both the administrative staff as well as Dr. Hull, and it is an inconvenience for you as well. If you run out of a medication because you missed an appointment then you will need to be seen to get your medication refilled (please do not call and ask for a refill in this circumstance). Controlled substances won’t be called in during office hours or on call (you must be seen for refills on controlled substance medications).
Medication Prior Authorization: When you take a prescription to your pharmacy you may be
told that your doctor needs to get approval for your medication from your insurance company. This is called a “prior authorization” or “PA.” Please understand that a PA for medications not
covered on your insurance without a PA is often a complicated and time-consuming process. Therefore, if such a PA is needed for a prescribed medication it may be handled promptly or there may be a delay (based upon how busy we are and the complexity of the PA). Dr. Hull will may need to change you to a covered medication; however, if you have previously failed or experienced intolerance to one or two “formulary alternatives” then Dr. Hull will likely be able to get your new medication approved. A service called “Cover My Meds”
(www.covermymeds.com) will be utilized to obtain your approval.
Canceling (or failing to show for) an appointment: If you need to cancel an appointment then please give at least a 24-hour business day notice. Failure to give adequate cancellation notice prevents another patient from being able to be seen; therefore, a full office charge of $100 will be assessed for failure to cancel your appointment in a timely fashion. Appointment reminders are not failsafe. We expect you to remember your appointment regardless of a reminder. Failure to show up for a scheduled appointment will result in a full $100 office charge.
On Call: Please limit after hour phone calls to true emergencies. As there is only one physician in our practice currently he is on call 24/7. If your needs are non-emergent then please wait until the next business day to call. If it is an emergency then please call 911.
Phone Calls: In general Dr. Hull does not handle medical-psychiatric visits over the phone – it increases the risk for sub-optimal medical care. Therefore, if you are calling for medical-psychiatric advice then you will be asked to schedule an appointment.
Forms & Letters: If you have a form that needs to be completed (or a letter written) then you will need to schedule an appointment, during which the form will be prepared (and you will incur a standard office visit charge for that visit). If, in Dr. Hull’s judgment, filling out the form (or writing the letter) does not require your presence then you will be charged based upon the amount of time it takes for the form to be completed or the letter written (charged at a $100 per 15 minutes of time spent – minimum charge $35). Please fill out as much of the form as you possibly can (even in the physician section).
Labs: If blood work is needed then you will be given an order. It may be drawn at your primary care physician’s office, at a local lab, the out-patient lab at your local hospital, or Dr. Hull may suggest that your labs are done at the Health Diagnostic Laboratory (HDL) in Peachtree City. In that case your insurance is billed for your labs, but you will not be balanced billed (i.e.: you will have no out-of-pocket cost). Otherwise, you will be given an order for your labs to take to the lab of your choice.
Since Dr. Hull is also a Family Physician will he treat my medical issues and / or refill my non-mental-health medications? Dr. Hull does have a Concierge medical practice that you may inquire about; however, outside of that he generally will not treat your medical problems or refill your other medications. This should be handled by your primary care physician or specialty physician.
Dr. Hull has been practicing medicine for well over twenty years, and continues to love what he does. ANSMC is committed to delivering the best medical care possible and we believe the aforementioned considerations will maximize your overall quality of care while maintaining a
vibrant and positive atmosphere in the office. We appreciate your cooperation with these guidelines. If you have any questions about these policies then please ask any of the ANSMC staff for clarification or more detailed explanation. It is our pleasure to serve you and we look forward for the opportunity to care for your needs. We thank you for entrusting Dr. Hull and the staff with your care. It is our mission to earn the right to maintain that trust.
Respectfully,
