PATIENT FINANCIAL AGREEMENT
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- Elmer Casey
- 5 years ago
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1 PATIENT FINANCIAL AGREEMENT Understanding our financial policies is an important part of your overall experience with our office and staff. Feel free to ask any questions you may have about this financial agreement. Please read these policies carefully and sign below, indicating that you have read and understand the policies detailed within. INSURANCE PARTICIPATION We are in network with many insurances, however it is your responsibility to know whether our services are covered on your policy. Our office does not accept any of the TennCare plans, or Health Springs. If you have out of network coverage on your policy, we can see you, but you will be responsible for any deductible from that coverage. OUR RESPONSIBILITY TO YOU 1. To file claims to your insurance company on your behalf, and make appropriate appeals when claims are denied initially. 2. To notify you if there is a problem with any of the claims. YOUR RESPONSIBILITY TO OUR OFFICE 1. To provide accurate and up-to-date insurance information to our office. Failure to provide us with this information may lead to denial of claims and cause you to be personally responsible for charges incurred. 2. To be responsible for any out-of-pocket expenses that are owed as dictated by your insurance coverage. Depending on your insurance coverage the may include any of the following types of payments: a. Co-Payment : a payment that may be required at the time of an office visit as a mechanism by which you share the cost of that visit with your insurance carrier. This is usually a flat fee paid per visit, regardless of the total amount of charges incurred. b. Co-Insurance : a payment that shares some of the overall cost of your care with your insurance carrier. This is usually determined after the charges have been processed by the insurance carrier and an Explanation of Benefits or E.O.B. has been issued. A plan will have a set ratio, for example 70/30, where the insurance carrier pays 70% of the allowed amount and you are responsible for 30%. c. Deductibles : these are amounts that are paid out by the patient before any payments are made by the insurance carrier. A $500 deductible means that the patient is responsible for paying the first $500 of the charges incurred. Once the deductible is met then your insurance carrier will begin covering their portion of the allowed charges. Deductibles can be per individual or per family. Deductibles usually reset every January 1 st. NO SHOW FEES: We require a 24-hour notice of cancellation. However, emergencies do happen. If we do not hear from you by 7AM on the day of appointment, you will be charged a $30.00 fee, new patients $ Your insurance company is not billed for this, you are responsible for this charge. I have read and agree to the policies listed above. I hereby authorize payment directly to. I realize that I am responsible for any uncovered charges Signature Date
2 Contact Information Sheet Patient Name: Date of Birth: Patient Signature: Preferred Pharmacy: Address: Location: Phone #: Home Phone# Do you have an answering machine? If yes, may we leave a message with Dr s name? Work# Do you have Voice Mail? If yes, may we leave a message with Dr s name? Mobile#_ Do you have Voice Mail? If yes, may we leave a message with Dr s name? May we leave a message regarding your appointments with someone other than you?
3 Acknowledgement of Receipt of tice of Privacy Practices & Receipt of Office Policies I have been presented with a copy of the tice of Privacy Practices, detailing how my health information may be used and disclosed as permitted under federal and state law, and outlining my rights regarding my health information. I have also been presented with a copy of the Office Policies & Procedures. Patient Printed Name Patient Signature Date Parent/Guardian Printed Name Signature Date
4 Patient Name: Referred by: What is the main problem you are seeking psychiatric help for? List difficulties / symptoms / issues which have prompted you to seek treatment: What, if anything, happened recently to make the problem worse? Please circle each symptom that relates to you: Depression Pain Perfectionistic Decreased interest Muscle tension Addicted to drugs / alcohol Weight loss / gain Excessive worry Feel ugly Feeling guilty Racing thoughts Feel empty Irritability Talkative Flashbacks Feeling agitated Excessive energy Extreme fatigue Worthlessness Paranoid Loud snoring Hopelessness Hearing voices Sleeping too much Diminished ability to think Seeing images Trouble getting to sleep Poor concentration Obsessive thoughts Trouble staying asleep Easily distracted Intrusive thoughts Jerking legs while asleep Difficulty staying on task Suicidal thoughts Panic attacks Have you ever been a patient of a psychiatrist? If yes, what was your diagnosis and how long were you treated? Have you ever been in talk therapy / psychotherapy? If yes, when and for how long?
5 List all CURRENT medications and dosages: Patient Name: Medication Allergies: List all medical illness you now have, or have had in the past: (including high blood pressure, diabetes, heart disease, etc.) Have any of your family members had psychiatric difficulties including depression, bipolar disorder (manic depression), alcohol abuse, anxiety, panic disorder or dementia? Relationship of Family Member Type of Psychiatric Problem Where were you born? Where did you grow up? Are your parents living? Are they married? Do you have any brothers/sisters? If so, how many? Are you married? Have you been divorced? If so, how many times? What do you like most about your spouse? What do you like least about your spouse? Do you have children? If so, how many? How far in school did you go?
6 Patient Name Are you employed? If so, what is your job? Have you ever been in the military? If yes, what branch and for how long? Do you have any history of childhood abuse / trauma? Whom do you currently live with? What would you say is currently the most stressful thing in your life right now? Do you attend church or a religious service? Do you drink alcohol? If yes, how much do you drink? Rarely Occasionally Frequently Have you ever tried to cut back your drinking unsuccessfully? Do you get annoyed at friends / family telling you that you need to drink less? Do you ever use alcohol first thing in the morning? Do you use tobacco? If yes, how much? Do you use cocaine / marijuana or other illegal drugs? Have you ever been arrested? Have you ever been through detox or rehab? I understand that this is part of my initial psychiatric evaluation and I have filled it out to the best of my ability. Patient Signature Date
7 Patient Name Have you ever attempted suicide? Have you ever been hospitalized for any psychiatric reason? If yes, how many times and for what reason? Have you ever taken any psychiatric medication? Some examples are: Adderall Cymbalta Lamictal Nuvigil Rexulti Valium Adderall XR Depakote Latuda Paxil Risperdal Viibryd Ambien Effexor XR Lexapro Paxil CR Ritalin Vraylar Ambien CR Evekeo Lithium Pristiq Rozerem Vyvanse Ativan Fetzima Lunesta Provigil Seroquel XR Wellbutrin Celexa Geodon Luvox CR Prozac Trazodone Xanax Concerta Klonopin Mydayis Restoril Trintellix Zyprexa Past Psychiatric Medications Taken Reason Discontinued Current treatment providers: (Please include therapists, primary care physicians, etc.) Name Role Phone Number
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Date: / / Name: Phone: E-Mail: Street: City: State: Zip: DOB: / / Age: Height Weight: Sex : M, F or Transgender (Please circle) Sexual Preference: Emergency Contact: Relationship: Phone: Employer: Job
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