PATIENT INFORMATION SUMMARY

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1 PERSONAL INFORMATION PATIENT INFORMATION SUMMARY 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 address Please circle your preferred Reminder Method: 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 Signature Date

2 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 $ The charge for missing an appointment without notification is $ 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 Patient Name (Printed) Relationship, if not the patient

3 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 Associates is 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 Date: Revised 8/26/2015

4 Patient Record of Disclosures 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. I wish to be contacted in the following manner (check all that apply): Home Telephone ( ) O.K. to leave message with detailed information Leave message with call-back number only Written communication O.K. to mail to my home address O.K. to mail to my work/office address O.K. to fax to this number ( ) Work Telephone ( ) O.K. to leave message with detailed information Leave message with call-back number only Cell Telephone ( ) O.K. to leave message with detailed information Leave message with call-back number only Other _ Patient/Guardian Signature Date Print Name of Patient Patient D.O.B FOR OFFICE USE ONLY: 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. Note: Uses and disclosures for TPO may be permitted without prior consent in an emergency. 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= ; M=Mail; O=Other

5 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 List any previous medications trials for mental health symptoms. Which pharmacy do you use? Have you ever had any of these illnesses? Cancer Type: Seizures Heart attack Asthma Artery disease Emphysema Heart arrhythmia Obstructive sleep apnea High blood pressure Arthritis High cholesterol Allergies Stroke Kidney disease Diabetes Anemia Liver disease Glaucoma Ulcers Thyroid disease Heartburn or reflux 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 Alcohol Abuse or Dependence Bipolar Disorder Drug Abuse or Dependence Anxiety Dementia or Alzheimer s Disease Panic Disorder Suicide Post-Traumatic Stress Disorder Unexplained Sudden Death Obsessive Compulsive Disorder ADD or ADHD Eating Disorder Borderline Personality Disorder List any other mental illness in your family

6 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. Are you employed? Yes No Are you a student? Yes No Current Occupation If so, where? How far did you go in school? Have you served in the military? Yes No Do you smoke or chew tobacco? Yes No Do you drink alcohol? Yes No Do you use any recreational drugs? Yes No If yes, describe service? If yes, how much per day? If yes, Occasionally 1 drink/day 2-3/day 4+/day If yes, list the drugs Do you currently have any of the following problems? Yes No Yes No General Constitutional Recent weight loss Females Pregnant Recent weight gain Nursing Fatigue Change in periods Fever Hot flashes Eyes Menopause Vision changes Musculoskeletal Eye pain Joint pain Ears, nose, mouth and throat Stiffness Runny nose Skin Ringing in ears Rash Sore throat Neurological Hearing loss Seizures Dry mouth Headache Cardiovascular Numbness Chest pain Limb weakness Dizziness/faintness Poor balance Loss of consciousness Endocrine Respiratory Tremor Cough Excess sweating Wheeze Thin hair Shortness of breath Dry skin Gastrointestinal Excess thirst Abdominal pain Excess hunger Nausea/vomiting Frequent urination Diarrhea Hematologic Constipation Excess bleeding Blood in stool Easy bruising Genitourinary Painful urination Allergic/immunologic Sneezing Loss of libido Itching Males Erectile dysfunction Hives For Office Use I have reviewed this information. Pertinent positives and negatives are documented in my note from today s visit. Page 2 of 2 M.D./ ARNP Signature Date Richard Hauser Kimberly VerHoef Todd VerHoef Dana Weibel Christopher Welsh Ann Glick

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