Syeda N. Sultana, M.D. Board Certified Child, Adolescent & Adult Psychiatrist

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1 Patient's First Name: Middle Name: Last Name: Sex: Marital Status: of Birth: Social Security Number: Patient's Address: Home Phone: Address: Primary Care Physician: Pharmacy: Mobile Phone: Referred by: Primary Care Physician Phone: Pharmacy Phone: Pharmacy Address: Employer/School: Employer/School Phone: Emergency Contact Name: Occupation: Employer/School Address: Emergency Contact Phone: Relationship to Patient: Primary Health Insurance Company: Plan: Plan Number: Group Number: Insured Employer/School: Relation to Patient: Insured's Address: Insured's Name: Insured's Phone Number: Insured's Social Security Number: Insured's Birthdate: 1

2 Responsible Party (If other than the patient): Billing Name: Relation to Patient: Reason For Visit: Phone: Address: Symptoms Started: List any current medications: Have you lost any days from work or school: How much caffeine do you drink per day: Are you currently employed: How would you identify your sexual orientation: How often do you exercise: Have you ever served in the military: Have you ever been arrested: Do you have any pending legal problems: Do you belong to a particular religion or spiritual group: Highest Educational Level Attained: Scheduling Appointments: Please prepare to confirm your appointment with Visa or Master Card; we will charge $1 on the card and keep it on file. Self-pay patients need to make the full payment to confirm appointment. There are charges to fill up paper work please see the payment agreement form. Our practice will always accommodate your scheduled time how ever due to the complexcity and emergency condition of the patient ahead of you, there may a delays or a long delays which circumstance is out of our hand. We appreciate your patience and cooperation during these times. Our staff will do everything possible to provide the best treatment you and your family needs. Please let us 2

3 know your urgency upon arrival for your visit. We request new patient to 35 minutes prior to the appointment time and 10 minutes prior to your follow up visit. The appointment is final. We may try to have courtesy reminder call for your schedule appointment. Patient is responsible to keep the appointment to avoid no show fees. What to Bring: We will need you to bring all your medication with the container with patient name and prescribing provider's information. We will need you to fill and bring these forms on our website prior to the time of your appointment. Also please fax or your Authorization for Release of Medical Record s Information to Previous Practitioner (Primary Care Doctor / Psychiatrist) * Authorization for Care & Treatment, HIPAA Regulation & Consent, Payments Agreement, Patient Questionnaire, Release of Medical Records Form. We must have your current valid Photo ID, if there is a Child or Adolescent, we will need Child s school Photo ID, prior Medical Records, prescribed medication with container and your copayment prior to the visitation with the provider. If you are adoptive parents, Care providers, Step Parents or Custodial Parents we will need official court order, adoption paper, official court orders with the authorization for the medication and treatment of the child and Adolescent patients. For a New Child or Adolescent patient we must have an initial visit with the parents only and then we will have an initial visit with the Child or Adolescent patient with the parents. The parents must bring the patient only no sibling at the time of the visit. For the Adult treatment of ADHD or ADD the provider s requires neuropsychological testing and urine drug screens before start of stimulant medications. 3

4 For the prior authorization of medication there may be a fees and will take 7 days to get approval by the prescription insurance company. Our office prescribe medication for 30 days only and requires a follow up visit to receive prescription. We must have the fees prior to the initiating FMLA/any paper work Office Policy: If the patient misplaces (including lost or stolen) a control substance prescription within the time period before the next appointment, the prescribing physician will not write another prescription. It is the patient s or guardian's sole responsibility to keep the prescription in a safe protected place. The call in prescription fees will be charged only if the patient requires a refill. For the safety of our patients and staff, please do not bring any food or drink, any concealed weapons, or any sharp items. Any photography and/or video recording is prohibited. Insurance DOES NOT cover over the phone conversations. If you need to have your appointment over the phone, conversations and therapies are charged at a $390 self-pay rate. Any patient with litigation must pay for all the litigation fees arising between the parties. They must indemnify and hold harmless to Bay Hill Psychiatric Associates, its staff, Dr. Syeda Sultana and all the providers for litigation, court ordered subpoenas, and compliance of court orders. We thank you for your patience and appointment request we will get back to as soon as possible to confirm you appointment. Please type and print your name below as an acknowledgement of all the terms and condition regarding your appointment with our office: Patient/Guardian Signature: Print Name: Patient of Birth: : 4

5 AUTHORIZATION FOR CARE AND TREATMENT Patient: Therapist: Syeda N. Sultana, M.D. of Birth: 1. I recognize that a condition exists requiring psychiatric/psychological care and do herby voluntarily consent to such care, medical care and treatment and diagnostic procedures by Bay Hill Psychiatric Associates, LLC (medical professional staffs, employees & agents) or as deemed necessary. 2. I hereby authorize the physician assigned, as provided by law, to furnish psychiatric/psychological care or therapy, including administration of psychiatric medication. 3. I am aware that the practice of medicine, including psychiatry and psychology, are not exact sciences, and I acknowledge that no guarantees have been made to me as to the result of diagnostic procedures, medical procedures, treatments, examinations or care undertaken. 4. The contents of this form have been fully explained to me and I have been given the opportunity to ask questions. Any questions which I have asked have been answered to my satisfaction. I certify that I understand the contents of this form and that all blanks have been crossed out or filled in. I UNDERSTAND THAT I AM ENTITLED TO AN EXACT COPY OF THIS AGREEMENT. Signature of Patient Witness Signature of patient s parent/guardian if the patient is under 18 years of age. This form has been filled out and explained to the person whose signature appears: Signature of Patient Witness 5

6 HIPPA REGULATION AND CONSENT: Required by the Health Insurance Portability and Accountability Act CFR Parts 160 and 164 I have previously received the HIPAA regulation and do not wish to receive a copy today. I have received a copy of the HIPAA regulation today Signature I hereby request the following regarding the use of my Personal Health Information: You may leave the following message on answering machines: 1. Referral information 2. Prescription refill information 3. Test results 4. Appointment reminder 5. All of the above You may contact me regarding my treatment and care at the following numbers: Home: Cell: Work: You may talk to the following people in my family about care, appointment, test results, etc: Name: Phone: Relation: Name: Phone: Relation: Witness: : If minor is unable to sign for himself/herself: Signature of the guardian: Witness: : : 6

7 PAYMENTS AGREEMENT: I clearly understand and agree that all services rendered to me personally and/or to a minor or other person under my guardianship are charged to my credit card directly to me and I am financially responsible for payment for the office visit. There are no refunds or charge backs for the services, (No show fees)missed appointments and other charges below: ASSIGNMENT AND RELEASE I, the undersigned have insurance coverage with: began: (Insurance company) All medical benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by Medicare/the Insurance Company. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all my insurance/financial institution submissions whether manual or electronic: Signature: I have read, understand and accept the payment instructions given to me at this time of my first visit. THIS SIGNED FORM WILL SERVE AS MY SIGNATURE ON FILE, UNLESS OTHERWISE SPECIFIED. I GIVE PERMISSION TO DR. SYEDA N. SULTANA TO TREAT ME/MY CHILD AS HER PATIENT IN HER OFFICE UNLESS OTHERWISE SPECIFIED IN WRITING. Signature: I am responsible as a self-pay patient an initial visit of $ & follow up visits at $ paid in advance at the time of Appointments. All Market place Insured patient may have to pay self pay rate until we receive payment from insurance company. After reviewing the EOB the refund will be provided to the Credit Card it was charged originally. If my insurance company refuses to confirm payment or my insurance expired at the time of my visit a selfpay visit rate will be charged to the credit card on file for the services. CANCELLATION AND OTHER CHARGE POLICY: I understand that I will be charged for appointments not kept and which were not canceled 48 hours (2 business days, excluding Tuesday) in advance of the appointment time. Since insurance companies cannot be billed, I will pay for missed appointments, and I am personally responsible and authorizing no show fess to be charges to my credit card on file for such payment(s). $ charge for new patient missed appointments; a $ charge for follow-up missed appointments. $230 for the self pay patient. $ charge for refill without office visit, call in or lost prescription, for returned check, any personal letters & any forms filled by the doctor. $ charge for short term, long term, Medicare, Social Security, disability, any insurance company, CPA, court, attorney & FMLA documents. Initials: I HEREBY AUTHORIZE SYEDA N. SULTANA, M.D. / BAY HILL PSYCHIATRIC ASSOCIATES, LLC TO RELEASE ALL INFORMATION NECESSARY TO SECURE PAYMENT AND ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND ACCEPTED THE FORGOING STATEMENTS. Signature: : DOB: Print name: SS#: D. License #: 7

8 RELEASE OF INFORMATION Required by the Health Insurance Portability and Accountability Act CFR Parts 160 and 164 I hereby Authorize: Bay Hill Psychiatric Associates, LLC Syeda N. Sultana, M.D. Fax: To: a. Release information to: Doctor s Name: b. Obtain information from: Office Name: c. Exchange information with: Address: Phone: Fax: The information requested or authorized for release or exchange pertains to: a. Mental Health b. Education c. HIV/Transmitted disease d. Drug or alcohol abuse This authorization is valid for 90 days from the date below or, whichever is earlier. I may cancel this authorization by signing, dating and writing CANCEL on this original form or by sending a written, signed and dated request to the doctor above indicating my desire to cancel. I understand that once my information has been released, the recipient might re-disclose it; my doctor has no control over it and privacy laws may no longer protect it. The purpose of this authorization is to improve the quality of my health evaluation and/or treatment. Patient Name (Printed) of Birth Patient Signature Signature of the witness: : Guardian s signature and date (if patient is a minor and/or unable to sign for him/herself). Patient s Name (Printed) 8

9 Patient Questionnaire: Syeda N. Sultana, M.D. Patient s Name: Age: Marital Status: Occupation: Depressed Mood [ ] Decreased Appetite [ ] Anxiety [ ] Increased Appetite [ ] Lack of Interest [ ] Guilt [ ] Increased Sleep [ ] Social Withdrawal [ ] Hopelessness [ ] Suicidal Thoughts [ ] Homicidal Thoughts [ ] Self-Destructive Acts [ ] Poor Concentration [ ] Mood Swings [ ] Muscle Tension [ ] Panic Attacks [ ] Headaches [ ] Obsessions [ ] Stomachaches [ ] Rituals [ ] Muscle Pain [ ] Hallucinations [ ] Back Pain [ ] Delusions [ ] Trauma [ ] Nightmares [ ] Dissociation [ ] Gambling [ ] Lying [ ] Phobias [ ] Alcohol Abuse [ ] Drug Abuse [ ] Seizures [ ] Inattention [ ] Blackouts [ ] Distractibility [ ] Hyperactivity [ ] Explosive Temper [ ] Impulsivity [ ] Poor Concentration [ ] Bedwetting [ ] Soiling [ ] Learning Problems [ ] Delayed Development [ ] Mental Retardation [ ] Place of Employment: If a student, grade level: School: Lives with: Who referred you to us? Check all that apply: List all current medications and dosages with name of prescribing physician: Allergies: Medical illnesses: _ Are you on medical leave? (Y/N). If yes, explain:. Are you in counseling? (Y/N) List all psychiatric hospitalizations and dates: History of physical abuse (Y/N)? Do you currently use drugs/alcohol/opioids or cigarettes (Y/N)? History of legal problems (Y/N)? Where were you born? City, State, Country Parents divorced (Y/N)? History of drug/alcohol/opioid or cigarette use (Y/N)? If yes, how old were you? Are you on probation (Y/N) How many brothers: sisters:? Birth order? Where were you raised? Signature: : 9

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