UPDATE FORM Name: (First) (Last) (Middle Initial) Address: Home Phone: Work/Other Phone. Social Security #: Date of Birth:

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1 COMPREHENSIVE PSYCHIATRIC CARE Psychopharmacology & Psychotherapy Adults, Adolescents, Children & Seniors UPDATE FORM 2011 Please fill out this form completely (front and back) Name: (First) (Last) (Middle Initial) Address: City: State: Zip: Home Phone: Work/Other Phone Social Security #: Date of Birth: Male / Female Marital Status: address: Under age 18: Yes / No If yes: Name of Parent/Legal Guardian bringing child to appointment: Employer/School Name: (Address) (City) (State & Zip) 2150 Peachford Road, Suite H, Atlanta, GA Tel: Fax:

2 COMPREHENSIVE PSYCHIATRIC CARE Psychopharmacology & Psychotherapy Adults, Adolescents, Children & Seniors INSURANCE POLICIES We understand that you wish to use your insurance benefits for our services; however, ultimately it is your responsibility to determine whether your doctor is in your network and to be aware of your current Mental Health insurance coverage. It is also necessary for you to obtain an authorization when required by your insurance company. In order to use your insurance for your upcoming visit, it is critical to complete the following Patient Insurance Verification form. You will want to contact your insurance company at the mental health phone number provided to you on your insurance card and ask a representative the following information. Without this form completed in its entirety, you will default to a Self-Pay status and be required to make payment in full at the time of service. We cannot file your insurance claims for you without the information. ****It is YOUR responsibility to inform our office of any changes in your insurance coverage.**** Sincerely, COMPREHENSIVE PSYCHIATRIC CARE

3 COMPREHENSIVE PSYCHIATRIC CARE Psychopharmacology & Psychotherapy Adults, Adolescents, Children & Seniors Patient Insurance Verification of Benefits Form (Please Complete in Full) Name and complete address: Date of Birth: Patient Social Security #: Home Phone: Policy Holder s Name: Policy Holder s DOB: Policy Holder s SS#: Employer: Insurance Company: Mental Health phone #: Policy ID# Group ID# Effective date: Mental Health Claims Address: contact your insurance company for this address, as it may be different than the one on your card *** ***Please MD Is Dr. Aleem in network? YES/NO Do you have out of network benefits? YES/NO Co-pay Amount $ Deductible Amount$ Has it been met How many visits per year are allowed? # Are authorizations required for a: 90801(new patient) YES/NO 90862(medication management) YES/NO Authorization # Auth Start Date: Auth End Date: How many visits are approved # Patient Signature: Rep: Date:

4 FINANCIAL TERMS AND OFFICE POLICIES We require that all patients call their insurance company and verify their benefits (which include co payments, co insurance, deductibles, number of visits allowed, and whether or not authorization for services is required). Due to the fact that some insurance companies sub out the mental health benefits to be administrated by another carrier, it is imperative that you call your insurance provider and verify that the doctor is in network and that outpatient mental health is covered. If authorization for treatment is required, you are solely responsible for obtaining authorization from your insurance carrier. Knowing your insurance benefits is YOUR responsibility. We will bill your insurance; however, you are responsible for co payment amounts and deductibles as set by your plan. We expect that fees be paid at the time of service. If for any reason we must bill you for fees, there is a $35 administrative charge for this service. We reserve the right to refuse to reschedule appointments if account balances are not paid. We are required by law to collect all co-pays at the time of service. Payments for co-pays, co-insurance, deductibles and other fees are due at the time the service is rendered. If you are unable to meet your financial commitment, you will have to reschedule your appointment. Missed appointments, disability evaluations, court ordered evaluations, completion of forms for attorneys or employers, copies of records, letters, or any other type of reports are not covered by your insurance and the charges associated with them are your responsibility. Full payment in advance is required for these services. Appointment Policies: Please be sure to call 24 hours in advance to cancel or reschedule your appointment. You will be charged the doctor/therapist full fee if you fail to do so. Our office utilizes an automatic appointment reminder system, so please be sure that we have your most recent telephone number on file to ensure that you receive the reminder call. Appointment reminder calls are attempted as a courtesy for you, but it is your responsibility to keep track of appointment dates and times.you may only call during business hours to cancel or reschedule/make appointments; our answering service does not take messages after hours regarding appointments. Please do not arrive more than 10 minutes early to your scheduled appointment time. Coming in earlier than the time you were scheduled and expecting to be seen early is inconsiderate to other patients and causes the doctor to run behind schedule. We highly recommend that you make a follow up appointment with Dr. Aleem before leaving the office to ensure that you get in within a timely fashion to renew your prescriptions. Dr. Aleem s schedule tends to book up rapidly, so do not wait until the last minute to make a follow up appointment. We do not allow babies or children in the office. This policy is 1) for their safety; and 2) so the doctor can concentrate on his patients. WALK INS: There is a 25$ fee for unscheduled walk in appointments. We will take walk in s for existing patients only. Please be aware that you will have to be considerate of other patients with scheduled appointments. Regardless of what your situation may be; you must wait until there is an opening. We can not guarantee how long you will have to wait. Walk ins place a tremendous strain on the doctors busy schedule and cause him to run behind. With that in mind, please do not make a habit of walking in with no appointment.

5 OFFICE VISITS Psychiatrists (MD) Our psychiatrists perform medication management; they do not provide counseling or psycho therapy. They also do not prescribe anything other than medication indicated for the treatment of psychiatric disorders. If you are in need of medication to treat a nonpsychiatric condition (for example, pain meds) you must follow up with a primary doctor or a pain management specialist; our doctors will not prescribe anything other than psychiatric medications. Do not ask the physician to make exceptions. PRESCRIPTION REFILL POLCIES First of all, you, the patient, are solely responsible for making sure that you do not run out of medication. It is also important that you take you medications according to the doctor s instructions. Please note that prescription refills are not automatically granted. Refill authorization is at the sole discretion of the physician. Our doctors have very busy schedules and at times it can take them up to 2 days to review your request. Please consider this fact when submitting your request or prior to contacting the office for information regarding the status of your request. There is also a 25$ charge for routine refills being called in/prescriptions being picked up due to missed, rescheduled, or in between appointments. Due to the fact that we receive a high volume of automatic faxes from pharmacies requesting refills, we require that patients call themselves (during normal business hours) to request refills. Because of the numerous requests we receive each day, we cannot personally call you to let you know that your prescription has been refilled. Please check with your pharmacy at the end of the business day for the status. On call physicians do not have access to your medical records; therefore, no prescriptions are called in after hours, on weekends, or holidays. Do not ask the physician to make an exception; Dr. Aleem is not on call to refill prescriptions. Do not call the after hours answering service to request refills; you must call during business hours. Non emergency calls to the answering service may incur a fee. Schedule II substances such as Adderall, Dexedrine, Concerta, Ritalin, and Vyvanse can not be called/faxed into a pharmacy and require a new written prescription from the doctor for each refill. Please note that if you are an existing patient and have not been seen by Dr. Aleem in the office in 6 months, an appointment may be required prior to refilling your prescriptions. Prescriptions requiring prior authorizations: Many insurance companies are limiting coverage by requiring prior authorization for some prescription medications. If your prescription requires prior authorization, please phone your insurance carrier and have them fax the appropriate forms to our office. Prior Authorizations are done on Fridays only, due to the fact that they are extremely time consuming. Please keep in mind that certain insurance companies can take up to 2 weeks to process these requests. Comprehensive Psychiatric Care is not responsible for your insurance company s decision in whether or not they will cover your medication. Samples of medication are given as a COURTESY to our patients; however, we can not mail out samples. Also, please understand that we have a limited supply of samples and can not render a substantial quantity of samples to any individual. We also can not guarantee that we will have samples of your medications; therefore, please do not depend on us to provide you with medication samples each month. If medication cost is an issue, please talk with your physician about your concerns.

6 Letters and Forms: There is a minimum turn around time of one week for requested medical records and letters. The minimum fee is $75.00 (seventy five dollars) and is not covered by insurance. Please keep in mind that Dr. Aleem must approve all letters before they are faxed, picked up, or mailed. The minimum turn around time for letters is one week, so please make sure you request letters one week in advance. Disability Claims If you are requesting assistance in completion of a disability claim, please make note of the following: 1. Comprehensive Psychiatric Care does not give disability. We can only report symptoms and response to treatment to the company that handles your disability insurance. 2. We do not backdate disability. 3. If regularly scheduled appointments are not kept, we will notify your disability carrier. 4. The doctor s first priority each day is to see the patients in the office; therefore, they will complete letters and forms as time permits. Disability paperwork requests can take up to 10 business days to complete. I have read and understand the office policies & procedures. Sign and Date Name (Please print)

7 PATIENT TREATMENT AGREEMENT I understand that this Agreement is essential to the trust & confidence necessary in a physician/patient relationship and that my physician undertakes treatment based on this agreement. I understand that if I breach this agreement my physician will be forced to stop prescribing controlled substances. I will not share, sell or trade my medication with anyone. I understand that my medications are my responsibility; I will safeguard my medication from loss or theft. I understand that lost or stolen medications will not be replaced under any circumstances. I understand that such mishandling of my medications is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal. I understand that refills of controlled substances will be made only at the time of an office appointment during normal business hours Refills for controlled medication will not be made over the phone. You must come to the office for an appointment. No refills will be made during evenings (after hours) or on weekends. I agree to take my medication exactly as prescribed so as to not run out of medication. I understand that use of my medication at a greater rate will result in my being without medication for a period of time. Our office does not provide early refills for medications; any medication dosage changes must be approved by the doctor. I agree to adhere to the payment policy outlined by this office. I agree to conduct myself in a courteous manner at all times when in the doctor s office. Inappropriate language/behavior towards administrative or clinical staff will not be tolerated. I agree to provide random urine samples for drug testing at Dr. Aleem s request. I understand that violation of the above may be grounds for termination from this practice. CPC will make all notifications of termination of care in writing. PATIENT SIGNATURE DATE

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