PATIENT DEMOGRAPHIC INFORMATION FORM

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1 If you did not complete these forms in advance and bring them with your initial appointment today, then please complete them, and sign them now. Our office does not receive from patients. We do use a patient portal system to send forms to be completed, and to send appointment reminders. If you have any reports for the Dr. Smith, we would appreciate them in advance. If you cannot get them to us by mail or fax in advance, please bring them with you to your appointment. PATIENT DEMOGRAPHIC INFORMATION FORM Today s Date PATIENT INFORMATION: Patient s Name Address City State Zip Home Phone# Mobile/Cel.# Work# **Please indicate preferable phone to use Age Date of Birth Social Sec. # Married Single Divorced Other Spouse s Name Mobile# Work# Employer Occupation Address City State Zip Pharmacy Name/City/Phone# Phone# REFERRAL INFORMATION: Referred By Phone # PRIMARY CARE PERSON AND OTHER PHYSICIANS: Family Physician Phone# OB/GYN Phone# Cardiologist Phone# Neurologist Phone# Rheumatologist Phone# Liver Doctor Phone# Kidney Doctor Phone# Other Specialist Phone# EMERGENCY CONTACT INFORMATION: Name Relationship Address Cellular Phone# Home Phone# Work Phone# Who is responsible for payment, if other than self? Name Relationship Address Phone

2 AUTHORIZATION TO DISCLOSE AND OBTAIN MEDICAL INFORMATION FORM Evidence supports including a primary support person or significant other in your treatment plan. Many clinical problems can occur if this permission is revoked. In order for us to better treat you, our office requests that you sign this Release of Information Form. Please read this form carefully, and discuss any questions that you may have about it with Dr. Smith or our office staff before signing it. We understand you may have specific privacy requests. Please list any specific privacy requests on this form (for example, if you are going through the process of a divorce, you may prefer for us to have no contact with your spouse, and therefore designate a different primary support person.) I understand that by signing this form, I give Dr. Donald A. Smith and his office staff permission to communicate clinical and medical information about to the people I list on this form, for the purpose of good continuity of care. I understand that by signing this form, I also give anyone I list on this form permission to communicate clinical and medical information about me to Dr. Smith and his office staff. Information about me that may be communicated, includes: my diagnoses, treatment, laboratory results, drug screening results, urine drug screening results, other clinical information; information about my substance abuse, miss-use or suspected diversion of controlled substances; and my HIV/AIDS status. I understand that by law, I am allowed to revoke this permission at any time, and that I will need to do so in writing, by signing the Revoke Permission for Release of Information Form. I understand and agree that if I chose to revoke permission for future communication with anyone on this form, Dr. Smith and his office staff will only be able to communicate to them that previous permission was revoked, and now he can neither confirm nor deny that I am currently being treated by him. I understand that if I revoke permission for Dr. Smith and his office staff to speak with any people listed on this form, it may result in immediate termination of care with Dr. Smith, based on Dr. Smith s clinical judgment, especially if I revoke permission for communication with people on this form, because I have violated either my Controlled Substance Medication Agreement, and/or my Treatment Contract. Emergency Contact Relationship Contact phone numbers Name of Significant Other or Spouse Relationship Name of Primary Care Person Office location Individual Therapist s Name Office location Group Therapist s Name Office location Other Medical Provider (Neurologist, Cardiologist, Kidney Specialist, etc ): Name Specialty Location Other Person Name Relationship My Specific Privacy Requests My signature below means that I have read, understand, and agree to the information on this form Signature of Patient Date Printed Name of Patient Date of Birth Signature of Legal Guardian of Patient Date Printed Name of Legal Guardian of Patient Phone Number of Legal Guardian This permission will expire one year from the date of my signature on this form, or on the following date

3 PAYMENT AND INSURANCE INFORMATION AGREEMENT I fully acknowledge that I am responsible for full payment of the total bill incurred, and that I will need to pay Dr. Smith by check or cash at the beginning of each appointment. I fully acknowledge that I am responsible for filing any forms to my insurance company. I understand that it is my responsibility to know what my insurance company requires, in order for me to be reimbursed, and that I need to let Dr. Smith know this information in advance. I understand that if there are delays in payments, or problems with receiving reimbursement from my insurance company, that it is my responsibility to contact my insurance company. By Signing below I acknowledge that I have read and understand the above, and I agree to these terms. Date Signature of person responsible for payment to Dr. Smith for patient named above on this form Printed name of person who signed above signature

4 RELEASE OF MEDICAL INFORMATION TO YOUR INSURANCE CARRIER FORM for the office of Donald A. Smith, MD Do you have Health Insurance? Yes No (If yes, complete the following form) Primary Insurance Co. Policy Holder Relationship Group # ID # (Subscriber #) This signature is to authorize the release of any necessary medical information to my insurance carrier. All clinical information about me may be released, including my diagnoses, lab results, information about substance abuse, HIV/AIDS, and other sexually transmitted diseases. I fully acknowledge that I am responsible for full payment of the total bill incurred. By signing below, I fully acknowledge that I have read this form and agree to the terms as outlined above. Date: Patient signature (Or Parent signature, if patient is a minor. Or Guardian signature) Printed name of signature

5 PRIVACY POLICY FORM for the office of Dr. Donald A. Smith, MD. It is my policy to not to release any information regarding your use of my services or your private and confidential information. However, with your written permission, my psychiatric services are better provided in collaboration with your therapist and any medical providers you may have. I use an electronic internet-based, medical record system (Valant), fax system (Valant), and prescription program (Valant and Dr. First); I, and those companies (Valant and Dr. First), am/are all required to keep your information protected under the requirements from the Health Care Information Portability and Accountability Act (HIPPA). The following conditions affect the confidentiality of your information: 1.) You may chose to provide written permission for me to release your records or other information about you, to anyone you chose to list on either of my two office forms: a.) Authorization Form to Disclose and Obtain Medical Information b.) Release of Medical Information to your Insurance Carrier Form You may revoke permission by signing the Revoke Permission for Release of Information Form, at any time. 2.) If I assess you to be at imminent risk of harming yourself or of harming someone else, then I am legally and ethically obligated to follow certain procedures and disclose information about you to try and keep you safe, and to try and keep anyone else who might me in danger safe. 3.) I am required under Massachusetts law, to report to the proper agency and/or authorities, any information about child abuse or neglect, elder abuse or neglect, or suspected child abuse or neglect, or suspected elder abuse or neglect. Once this information is reported, the proper agencies and/or authorities may gather additional information and/or decide to conduct a formal investigation. 4.) A court order, written by a judge, could require me to disclose your private information, but that happens very rarely. I would notify you of such a court order, prior to disclosing any of your information, so that we can discuss this together with your legal counsel. If this were to happen, I would do my best, within the law, to try and limit the information shared about you, to only the information needed to answer the legal questions or charges. Please visit the following website for additional information: If you have questions about this privacy policy, please ask me. Your signature acknowledges that you have read the above statement and agree to these conditions. Date: Patient signature (Or Parent signature, if patient is a minor. Or Guardian signature) Printed Name of Signature

6 ACKNOWLEDGMENT OF PRIVACY POLICY AND OFFICE POLICY AND PROCEDURE FORMS This copy or your signature is for Dr. Smith s records. I fully acknowledge that I have read and understood Dr. Smith s Office Privacy Policy, and that I have had time to ask questions, and those questions were answered to my understanding by Dr. Smith or his office staff. I fully acknowledge that I have read and understood Dr. Smith s Office Policies and Procedures Form, and that I have had time to ask questions, and those questions were answered to my understanding by Dr. Smith or his office staff. I have been provided with a copy of both Dr. Smith s Privacy Policy Form and Office Policies and Procedures Form that I have signed and dated, to keep for my own records. My signature below verifies that I have read, understood, and agree to the terms as written in both Dr. Smith s Privacy Policy Form, and Dr. Smith s Office Policies and Procedures Form. Date: Patient signature (Or Parent signature, if patient is a minor. Or Guardian signature) Printed name of signature

7 OFFICE POLICIES AND PROCEDURES FORM for the office of Donald A. Smith, MD (patient copy to keep for their records) The following information is intended to explain policies and procedures of services provided by the office of Dr. Smith. Please read through the details thoroughly and discuss any questions you may have prior to signing it. A.) AVAILABILITY: Dr. Smith has an individual, private, part-time, psychiatry practice whose service is intended to compliment the services you receive from your primary care provider and your individual therapist. The combination of medication and therapy is better than either treatment alone. You need to either already have an established relationship with a therapist, or be willing to establish one after your initial visit with Dr. Smith, in order to have Dr. Smith serve as your psychiatrist. As you progress in treatment, this requirement might be waived. The office is open on Tuesdays, Wednesdays, and Thursdays from 9:00am-5:00pm. Appointments outside this timeframe will be considered based on availability, and additional fees apply. B.) REFERRALS: 1.) Self- Referrals: You may request on your own, for Dr. Smith to be your psychiatrist, as long as you either have an established relationship with a therapist, social worker, or psychologist prior to your initial appointment, or if you are willing to get one. 2.) Therapist Referrals: Your therapist may refer you to see Dr. Smith, for medication evaluation and treatment. 3.) Primary Care Provider Referrals: Your Primary Care Provider may refer you to Dr. Smith, as long as you either have an established relationship with a therapist, social worker, or psychologist prior to your initial appointment, or you are willing to get one. C.) PAYMENT: Our office provides a Fee-for Service payment model. Although this can be a minor inconvenience to you, it allows Dr. Smith to spend more time with you each visit, and improves the quality of the care provided. For your insurance company purposes, Dr. Smith is an Out-of-Network Provider provider. Full payment is expected at the beginning of each visit, by check, or cash. You will be given a computerized bill and payment receipt at the end of each visit. These documents contain the information required by most insurance companies. You may attach the form you receive from our office to your insurance claim form and submit it by mail to your insurance company for reimbursement. Please know, the responsibility for filing these forms is entirely yours. Please understand that you, not your insurance company, are responsible for full payment of your account. Please consult with your insurance so that you understand the requirements, costs, correct form to submit, and their reimbursement rates to you. D.) APPOINTMENTS: 1.) Transfer of care Initial appointment If you have been treated by another psychiatrist, and Dr. Smith has agreed to this transfer, then your initial appointment will be between minutes. In these cases, you current psychiatrist will have reviewed your case with Dr. Smith, and provided Dr. Smith with a summary and relevant documentation regarding your care prior to your appointment. Please note, that being referred to Dr. Smith is not the same as a transfer of care arrangement with your current psychiatrist. At the present time, the only transfer of care arrangement that Dr. Smith has is with Dr. Robert Gardiner s and his patients. In transfer of care Dr. Smith will be continuing your care, so you will usually not have to repeat all of the information you discussed with your previous psychiatrist. Scripts for any medication refills you need will be provided by Dr. Smith at this transfer of care initial appointment. Please bring all of Dr. Smith s forms that you completed, to your initial appointment, even if Dr. Gardiner s office has already given them to us. 2.) Initial appointment (does not apply for transfer of care patients: Your initial appointment will last for 45 to 90 minutes. The initial appointment involves history gathering, safety evaluation, and diagnosis only. In some cases, no psychiatric medication is prescribed at this initial appointment. Either during or after your initial appointment, Dr. Smith will gather additional information, with your written permission and as needed, from secondary informants (for example from family members, significant other, and previous providers.) A tentative second appointment time may be scheduled with you at the end of your initial appointment. Our office will then contact you and your therapist or Primary Care provider to inform you both if Dr. Smith will be able to be your psychiatrist. This decision is based on our evaluation of your needs, and appropriateness of fit, based on the level of care needed, and types and amount of services our office is able to provide to you. If Dr. Smith agrees to be your psychiatrist, a second appointment will be held. By the end of your second visit a care agreement and treatment contract is established with Dr. Smith. At the time of scheduling your initial appointment, our office will block out time in the schedule, to allow a second appointment to happen as soon as possible, usually within 1-2 weeks. 3.) Second appointment (does not apply for transfer of care patients): Your second appointment will last from minutes. Dr. Smith will review your diagnoses, provide education, and establish an initial treatment plan with your input and approval. Any relevant forms will be reviewed and signed by you. By the end of the second appointment, if an actual care agreement is established, Dr. Smith will then technically be your psychiatrist at that time. If a care agreement is not established, our office is not required to find you a psychiatrist, but Dr. Smith may discuss with you and your referring provider possible recommendations. 4.) Follow-up Medication Management Sessions: Follow-up medication management appointments are scheduled for 20 minutes, unless otherwise specified. Dr. Smith will discuss with you how often you will need to meet with him. In general, plan on meeting with him about once per month for the first few months, and then every 2-4 months after that. In some cases, for example, if you have been stable on the same medication and dose for several years, it may be possible to see Dr. Smith every 6 months. Most patients will need to be seen every 3 months. 5.) Follow-up Therapy and Combined Therapy-Medication Management Sessions:

8 Follow-up Therapy and Combined Therapy-Medication Management Sessions are scheduled for 45 minutes, unless otherwise specified. These types of follow-up sessions usually occur every 1-2 weeks, exceptions may apply. We recommend you arrive 15 minutes early before your first appointment, and then between 5-10 minutes early for follow-up appointments. There is almost always plenty of parking at our building. If our office is running late, in very rare cases (for example if another patient is having an emergency), we will try to contact you at your preferred phone number ahead of time, and we will post information on Dr. Smith s website and on his office door. If our office is running more than 30 minutes late, and you are not able to wait, you will not be charged any fees, and will be rescheduled as soon as possible. Please remember, that if you were to have an emergency in the future, that same service would be provided to you. E.) COMMUNICATIONS: a.) Phone Calls and Voic s: Our office or a covering provider, will review voic s, at least three times each day, during Dr. Smith s office hours. When you call, you can leave a non-urgent voic , or to communicate a more urgent message, you can follow the prompts to press the * key, which will forward your call to Dr. Smith s or a covering provider s, mobile phone number. Non-urgent calls will be returned as soon as possible, usually between 8:30-9:00am and 4:30-5:00pm during Dr. Smith s office hours. Dr. Smith makes every effort to reply to all calls within a reasonable time, but does not interrupt another patient s session to answer phone calls. Dr. Smith will try to return urgent messages within 2-3 hours, or as soon as he is able to call you. When you call, please leave your full name, date of birth, phone number, reason you are calling, and our office will contact you during the times we return calls. If you are not available to be reached during the times we return calls, and you need to speak with us, please schedule an appointment with Dr. Smith. * Please let our office know if it is not O.K. to leave voic messages at your preferred contact number. b.) Our office does not receive from patients. But, our electronic medical record system will send you appointment reminders and any forms that need to be completed. F.) CHARTING AND PRESCRIPTIONS: Our office uses state-of-the art, web-based electronic medical record and web-based medication prescribing systems; which maintain your records confidentially, under the HIPPA requirements, and make it safer to get medications and refills. G.) MEDICATION REFILLS: Medication evaluation, dose adjustment, and refills are all done during your appointments. Our office will provide you with refills to last until your next scheduled appointment. If you are on a medication that can be filled without requiring a written prescription, you need only call the pharmacy and ask for a refill, even if your prescription bottles says no refills left. They will call or fax our office for authorization. Please try to anticipate your medication needs and call for refills when we are in the office. If for some reason you miss your appointment, please inform our office if you need medication to last until your next appointment. You will need to see Dr. Smith every 3 months, unless otherwise informed by Dr. Smith. However, medication refills will not be provided if you have gone beyond 6 months without evaluation by Dr. Smith; at that time you must be evaluated in person to get medication refills. H.) CHARGES, FEES, OUTSTANDING BALANCE, FINANCIAL HARDSHIP: 1.) Initial Consultation and Evaluation - 45 min $250 2.) Follow up to Initial Consultation min $150 3.) Medication management -10 to 25 min $150 4.) Individual Psychotherapy--45 to 60 min $250 5.) Special Documentation Preparation: i.e workers compensation, advocacy letter, employment, disability, etc $100/hr. 6.) Phone Sessions Equivalent appointment fees 7.) Extended Phone Calls Equivalent appointment fees 8.)Administrative Time Fee: If you need us to communicate by phone with your insurance company, or for other miscellaneous needs, that cannot be addressed during your appointments $100/per hour *per hour fees are rounded up to the nearest ¼ hour. 9.) Printing and photocopy charges may be applied for documentation requests. 10.) Appointment times outside of our regular office hours: We recognize that based on your work and life schedule, you may prefer a more convenient appointment time, for example before or after your work, or on the weekend. Similar to other professions, premium surcharges apply to these appointment times, which are limited, and also based on Dr. Smith s availability. 1.) Early Morning Appointments (6:00am-8:30am) 25% surcharge to all fees 2.) Early Evening Appointments (5:00pm-8:00pm) 35% Surcharge to all fees 3.) Weekend Appointments 45% Surcharge to all fees * Missed appointment full-fee charges apply to all of these appointment times, no exceptions 11.) Cancellation Fees: See below, Cancellation Policy. 12.) Returned Check Fee: If a check is returned due to insufficient funds, a $25.00 additional fee is charged.

9 13.) Outstanding balances: If you do not arrange a payment plan, accounts outstanding for more than 90 days will be sent to our collections agency. 14.) Payment Plans: Payment plans are available to divide your estimated yearly costs to equal monthly payment installments. To calculate your cost, remember to subtract the estimated amount your insurance company will reimburse you. 15.) Financial Hardship: You may ask Dr. Smith if reduced fee rates might be available to you in times of significant financial hardship. Please bring your W2 form, proof of unemployment, and any other relevant documents for review; or, a request for reduced fees for you can be made by your referring provider if they are providing reduced fees and have already verified these documents I.) CANCELLATION POLICY: 1.) If you cancel or reschedule your appointment at least 24 hours prior to your appointment time, you will not be charged any fees. 2.) If you cancel or reschedule an appointment less than 24 hours prior to your scheduled initial appointment, and if we cannot fill your scheduled time with another patient, then you may be charged a fee for your missed or cancelled appointment. i.) 1st cancellation less than 24 hours prior to your appointment will not be penalized. iii.) 2 nd cancellation less than 24 hours prior to your appointment will result in a fee equivalent to ½ the amount the visit fee. IV.) 3rd cancellation less than 24 hours prior to your appointment will result in a fee equal to the full amount of the visit fee. 3) Exceptions will be dealt with on a case-by-case basis and are at the discretion of Dr. Smith. 4.) Please call our office as soon as you know you will either miss, or not arrive in time for you appointment, to determine if a phone session might be possible. You will not be charged a cancelled appointment fee if we are able to fill your appointment time with another patient, or if Dr. Smith determines a phone session will be possible. *Please note that most insurance carriers will not reimburse you for cancelled or missed appointments fees. Please also check with your insurance company prior to see if they reimburse for phone sessions. J.) TERMINATION OF CARE: 1.) If you terminate or fire your current therapist, and do not already have a new therapist established, and/or if your mental health needs are too great to be safely managed by a part-time individual psychiatrist, then Dr. Smith reserves the right to refer you to more appropriate psychiatric care (for example a full-time psychiatric group, a psychiatric hospital, or a mental health clinic) who can better and more safely meet your needs. 2.) If your individual therapist determines that you do not need additional therapy after a period of treatment, but your individual therapist is willing and able to treat you again, as needed (for example, if you are in crisis), then Dr. Smith may be able to still be your psychiatrist, but that decision will be determined at that time. 3.) Any of the following may be grounds for termination of care: I.) Refusal at any time to allow Dr. Smith to communicate with your primary support network, or current or previous mental health providers. II.) Refusal or non-adherence to your signed treatment plan, established and agreed to by you and Dr. Smith; including completion of necessary lab-work and prompt random drug screening. III.) Suspected miss-use, over-use, or diversion of controlled substances. IV.) Missing an unreasonable amount of appointments. V.) More than one bounced check or significant unpaid balances. VI.) Not agreeing to set up a reasonable payment plan for unpaid balances K.) MEDICARE AND MEDICAID PATIENTS: Patients with Medicare and Medicaid Insurances can be treated by Dr. Smith, but will need to pay out-of-pocket. Our office was informed by The Medicare Administration that neither Medicare nor supplemental Medicare insurances would provide reimbursement to you if you see an out-of-network provider at the present time. Please contact Medicare or Medicaid and your supplemental insurances to double check this information. If you are already a patient of Dr. Smith s, and you plan to apply for Medicare or Medicaid insurance, then you will need to let us know immediately. L.) EMERGENCIES: In the event of a psychiatric emergency, please call 911, or call Emergency Mental Health Services at , or find a way to safely get to your nearest emergency room. Please make sure Dr. Smith is contacted by whoever evaluates you during the emergency. IF YOU ARE NOT SURE IF YOUR SITUATION IS URGENT OR AN EMERGENCY, PLEASE BE ON THE SAFE SIDE AND TREAT IT LIKE AN EMERGENCY. REMEMBER THAT IT COULD BE SEVERAL HOURS BEFORE DR. SMITH IS ABLE TO RETURN AN URGENT PHONE CALL. PLEASE PLAN AHEAD FOR MEDICATION REFILLS, AS THESE REQUESTS ARE SOMETIMES NOT CONSIDERED EMERGENCY SITUATIONS.

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