Comprehensive,Behavioral,Healthcare,of,Central,Florida,,LLC, Lawrence,B.,Erlich,,M.D., New,Patient,Intake,Forms,

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1 Comprehensive,Behavioral,Healthcare,of,Central,Florida,,LLC, Lawrence,B.,Erlich,,M.D., New,Patient,Intake,Forms, PATIENT INFORMATION Last Name/ First Name/ M.I. Social Security Number: Date of Birth (MM/DD/YY): Age: Sex: Male Female How did you hear about us? Primary Phone: Secondary Phone (optional): Street Address: City State Zip Address: Employer: Occupation: If we need to contact you, would you prefer: A non-identifying voic message ( This is Joe, please call me at ) A message identifying us as Dr. Erlich s Office or Comprehensive Behavioral Healthcare ( This is Joe with Dr. Erlich s Office, please call me at. ) Marital Status: Single Married Committed Relationship Divorced Separated Widowed EMERGENCY CONTACT INFORMATION Emergency Contact Name: Phone Number: Relation To Patient: Is there anyone that you give Lawrence B. Erlich, M.D and his staff permission to speak to regarding your care? Emergency Contact Other: Name: Phone: Relation: Name: Phone: Relation: INSURANCE Primary Insurance Carrier: Insurance Address: Policy Number: Group or Account Number: Policy Holder s Name: Relationship: Policy Holder s Date of Birth: Policy Holder s SS# Policy Holder s Employer: Policy Holder s Work Phone: Policy Holders Address:,

2 , HEATH HISTORY List any diagnosed behavioral health or medical problems: Have you ever had suicidal thoughts? If you had those thoughts, what would stop you from hurting yourself? List any medications that you are taking: Name Dosage Frequency List any drug allergies: List any non-medication allergies: Have you ever been in a drug or alcohol treatment program before? If yes, what kind of treatment and for how long? HEALTH HABITS Alcohol Do you drink alcohol? How many drinks do you have per week? Do you want to stop drinking alcohol? Have you ever had a blackout? If yes, how recently was your last blackout?,

3 , Tobacco Drugs Do you ever drink and then drive? Do you use tobacco? Cigarettes Chew Tobacco Pipe Cigars Per day: Do you want to stop smoking or chewing tobacco? Do you abuse prescribed medication or illegal drugs? If yes, what are you currently taking? Do you want to stop taking these medications or drugs? SOCIAL AND FAMILY HISTORY What are you seeking treatment for? Do you have any open legal cases? If yes, what are they? List any illnesses that run in your family. List any behavioral health problems that run in your family. Is there is a history of addiction in your family? If yes, please explain. How many times have you been married, if it all?,

4 , How many children do you have and what are their ages? Do you have a relationship with your children? How far did you go in school? Would you like to continue your education? Are you currently working? What do you do? Do you have a religion? If yes, do you go to services? Are you on disability or pension? If no, are you seeking disability? Do you have any hobbies? Please provide the name and phone number or address of the pharmacy that you prefer. Turner Drugs (located in building) Other: The above information is true to the best of my knowledge. I understand that I am financially responsible for any balance, and that all charges will be discussed with me before treatment. I hereby give my consent for treatment by Lawrence B. Erlich, M.D. I have been given the opportunity to review the privacy practices of Lawrence B. Erlich, M.D. and Imagine Recovery as required by HIPAA laws. X Patient Signature Date,

5 Comprehensive Behavioral Healthcare of Central Florida, LLC Lawrence B. Erlich, M.D Celebration Blvd, Suite 406 Celebration, Florida Insurance Waiver of Liability Patient s Name: Insurance Name: Date of Birth: Policy Number: Your insurance carrier will only pay for services they deem to be reasonable and necessary. If they decide that the particular service provided for you, although it may be otherwise covered, was not reasonable and necessary under the current circumstances, they will deny payment for this service. Although the doctor deems the service listed below is in your best medical interest, it is possible that your insurance will deny payment for this service. My physician has notified me that my insurance may deny payment for the service below for the reason(s) stated. If my insurance denies payment, I agree to be fully responsible for payment. Date: Service: Charge: Signature

6 Comprehensive Behavioral Heathcare of Central Florida, LLC Lawrence B. Erlich, M.D. HIPAA Information Form The Health Insurance Portability and Accountability Act of 1996 (HIPPA) provides safeguards to protect your privacy. These safeguards include restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include normal interchange of information necessary to provide you or your family with treatment. HIPAA provides certain rights and protections to you as a patient. We must balance these needs with our goal of providing you with quality service and care. Additional information is available by calling the U.S. Department of Health and Human Services or at For this reason, our practice has adopted the following policies. (1) Patient information will be kept confidential except as is necessary to provide treatment or ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories as is necessary and appropriate for your care. The patient agrees to the normal procedures utilized within the facility for the handling of charts, patient records, PHI and other documents or information. (2) It is the policy of this office to remind patients of their appointments. We may do this by telephone, e- mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative. (3) The patient understands and agrees to inspections of the office and the review of documents that may include PHI by government agencies or insurance companies in the normal performance of their duties. (4) The patient agrees to bring any concerns or complaints regarding privacy to the attention of the Doctor or office manager. (5) Your confidential information will not be used for purposes of advertising or marketing of products, goods or services. (6) The practice may change, add, delete or modify any of these provisions to better serve the needs of both the practice and that patient. (7) We agree to provide patients with access to their records in accordance with state and federal laws. (8) You have the right to request restrictions in the use of your protected health information and to request changes in certain policies used within the office concerning your PHI. However, the practice is under no obligation to alter policies to conform to your request. (9) There is no patient right to litigation under HIPAA. HIPAA CONSENT AND ACKNOWLEDGEMENT FORM I, (Patient) do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA Information Form and any subsequent changes in office policy. I understand that this consent and acknowledgement shall remain in force indefinitely. (Signature) (Date)

7 Comprehensive Behavioral Healthcare of Central Florida, LLC Lawrence B. Erlich, M.D. OFFICE POLICY CONSENT FORM Please read and initial each of the statements below. Your initials indicate a full understanding of each point. If you have any questions, please ask prior to initialing and signing the bottom of the page 1. There is a 48-hour cancellation policy on all appointments. Patients will be billed for the full fee of any appointments cancelled with less than 48 hours notice. Insurance does not cover missed appointments and the patient is responsible for paying these charges in full. Please speak with the office staff if there are any questions regarding this policy. 2. Patients will be billed for the full fee of any missed appointments. Insurance does not cover missed appointments, and the patient is responsible for paying these charges in full. Please speak with the office staff if there are any questions regarding this policy. 3. We accept cash and credit cards only. Personal checks are not accepted. 4. Patients must contact us for an appointment for medication refills. Prescriptions cannot be refilled by phone. Please speak with the office staff if there are any questions regarding this policy. 5. We encourage family members, spouses and significant others to be involved in treatment. Involvement of other parties is at the sole discretion of the patient. We require consent from the patient for each person who the patient allows to be part of his or her treatment. The patient reserves the right to rescind this consent at any time. 6. Any information provided to the staff of our office is completely confidential. If using insurance, the insurance company can request medical records as well as information to determine medical necessity. Patients will be informed of any contact made by the insurance company in reference to records or treatment information. 7. Patients are encouraged to call the office with questions about treatment or instructions. Our staff is available to answer questions and consult with the doctor on your behalf. If you have questions or concerns about medication or treatment, call our office immediately to clarify instructions. Please do not consult the Internet or other people for answers before consulting the doctor. We are available to answer questions when you have them. Please utilize this resource if necessary. 8. If you have any open legal cases, you must inform the office staff prior to being seen by the doctor. Open legal cases change the terms of confidentiality with the doctor, and the potential issues as well as fees must be explained prior to seeing the doctor. OFFICE POLICY CONSENT FORM I, (Patient) do hereby consent and acknowledge my agreement to the terms set forth in the Office Policy Consent Form and any subsequent changes in office policy. I understand that this consent and acknowledgement shall remain in force indefinitely. (Signature) (Date)

8 . Comprehensive Behavioral Healthcare of Central Florida, LLC Lawrence B. Erlich, M.D. Release of Records Form Please mail or fax patient medical records to: Phone: Fax: Patient Information: 1530 Celebration Blvd., Suite 406 Celebration, Florida Name: Date of Birth: SS#: Address: This letter will authorize you to provide a copy, summery or narrative of my medical records (as indicated by the check mark(s) below) or to otherwise release confidential information. At this time, I am requesting the following: Please obtain records from: Address: Phone: Fax: Complete Record Record of Care from to only Records of Care concerning the following condition: Other: HIV/AIDS: I consent to the release of any positive or negative test results for AIDS or HIV infection, antibodies to AIDS, or infection with any other causative agent of AIDS, with the rest of my medical records. Patient Signature: Date:

9 DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure Adult Name: Age: Sex: Male Female Date: If this questionnaire is completed by an informant, what is your relationship with the individual? In a typical week, approximately how much time do you spend with the individual? hours/week Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS. During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems? ne t at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days I. 1. Little interest or pleasure in doing things? 2. Feeling down, depressed, or hopeless? II. 3. Feeling more irritated, grouchy, or angry than usual? III. 4. Sleeping less than usual, but still have a lot of energy? Severe Nearly every day Highest Domain Score (clinician) 5. Starting lots more projects than usual or doing more risky things than usual? IV. 6. Feeling nervous, anxious, frightened, worried, or on edge? 7. Feeling panic or being frightened? 8. Avoiding situations that make you anxious? V. 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? 10. Feeling that your illnesses are not being taken seriously enough? VI. 11. Thoughts of actually hurting yourself? VII. 12. Hearing things other people couldn t hear, such as voices even when no one was around? 13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking? VIII. 14. Problems with sleep that affected your sleep quality over all? IX. 15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)? X. 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? XI. 17. Feeling driven to perform certain behaviors or mental acts over and over again? 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories? XII. 19. t knowing who you really are or what you want out of life? 20. t feeling close to other people or enjoying your relationships with them? XIII. 21. Drinking at least 4 drinks of any kind of alcohol in a single day? 22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? 23. Using any of the following medicines ON YOUR OWN, that is, without a doctor s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]? Copyright 2013 American Psychiatric Association. All Rights Reserved. This material can be reproduced without permission by researchers and by clinicians for use with their patients.