VIJAPURA BEHAVIORAL HEALTH, LLC 9141 Cypress Green Drive, Ste 1 Jacksonville, FL Phone: Fax:

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9141 Cypress Green Drive, Ste 1 Jacksonville, FL 32256 Angela White, ARNP, Ph.D. Demographics Patient Name: SSN: DOB: Email address: Street Address: Occupation: City, State, Zip: Cell Work/Home May we contact you and leave a message at your listed cell phone?

1 9141 Cypress Green Drive, Ste 1 Jacksonville, FL Angela White, ARNP, Ph.D. Demographics Patient Name: SSN: DOB: address: Street Address: Occupation: City, State, Zip: Cell Work/Home May we contact you and leave a message at your listed cell phone? YES NO Best time for us to call? If you require services outlined in the American Disabilities Act, please indicate here: Insurance IMPORTANT: We will need a copy of your insurance card, both front and back before making an appointment. Name of person who is legally responsible for bill: Policy Holder Name: SSN: DOB: Policy Holder Address: Policy Holder Employer: Primary Insurance Carrier: City, State, ZIP: Group #: ID #: Secondary Insurance Carrier: Group #: ID #: Guardian Info (for minors) Guardian Name: SSN: DOB: address: Street Address: City, State, ZIP: Cell Emergency Contact Work/Home Name: Relationship: Cell #: Provider Info Are you interested in participating in future clinical trials? YES NO Were you referred to a specific provider in our office? YES NO If yes to whom: Amit Vijapura MD Sagar Vijapura MD Lindsay McKim PhD, ARNP Angela White PhD, ARNP Susan Kessler ARNP Kelly Mitchell LMHC Referring Provider: Current Therapist: Primary Care Physician: Last Psychiatric Provider:

2 Presenting Issue(s) Describe what is bothering you, when started, treatments tried, tests performed, severity, and other symptoms. Previous psychiatric diagnoses: Medical/Psychiatric History Previous Suicide Attempts? yes no If yes, when was your last attempt? # of Psychiatric Hospitalizations: If yes, when was your last hospitalization? Please list all psychiatric medications you have tried, your response, and any side effects. Please list your medical conditions: Have you ever had a seizure? YES NO Please list current medications with dosage: Have you ever had head trauma with loss of consciousness YES NO Please list any allergies to medications: Family & Social History Please list any family members with a history of psychiatric illness, alcohol/substance abuse, suicide attempts. How many cigarettes per day do you smoke? : NONE less than or more How often do you have a drink containing alcohol? Monthly or Less 2-4X/month 2-3 X/week 4 X/week or more On days that you do drink alcohol, how many drinks you have in a given day? or more Which drug(s) have you used in the past year? None Marijuana Cocaine Pain Pills Heroin Benzos Other What is your marital status? Single Married Widowed Separated Divorced Children? YES NO What is your highest level of education? GED high school grad some college college grad graduate school

3 FINANCIAL AGREEMENT BILLING AND INSURANCE I understand, agree, and accept the following terms: All payments and/or co-payments are payable on the day of service, prior to the appointment. I am directly and fully responsible for charges not covered by my insurance company, such as co-payments, deductibles, and balances for non-covered services. Such payment is not contingent on any settlement, judgment, or insurance payment by which I might recover said fee. If my insurance company fails to pay my balance in full, or there is no payment made within 60 days, it is my responsibility to pay for services rendered. If I fail to notify VBH of any changes to my insurance provider or policy prior to my next appointment, I will be responsible for any charges not covered by my insurance company. If I fail to make timely payments on my account, I will be responsible for any and all reasonable costs of collection, including filing fees, as well as, attorney s fees. I understand that any outstanding balance of 90 days with no attempt to pay will be turned over to collections. If my account is turned over to collections, I must contact the agency of payments. I understand that it will be up to discretion of the office to re-accept me as a patient back to VBH once my account has been in Collections. I acknowledge and agree that Frost-Arnett (FA) and any affiliates or vendor thereof, including collection or billing companies, may contact me by telephone or text message to any numbers associated with my account. I further agree that I will notify FA if I have given ownership or control of any such telephone number. If I use a credit card for payment and I am not the cardholder, I will supply a notarized statement from the cardholder. There will be a $25 charge on all returned checks. NON-COVERED SERVICES AGREEMENT I understand that VBH will make every effort to make sure my treatment is authorized by my insurance company. However, in the event that my insurance company refuses, for any reason, to authorize services as medically necessary, I understand, agree, and accept that I will be responsible for all charges associated with my care. MEDICAL FORMS & MEDICAL RECORDS FEES I understand that VBH will be happy to provide a letter from my provider, medical forms completed by my provider, or medical records sent on my behalf. However, I understand, agree, and accept that there will be a fee for these services, due at the time of the request, which is not billable to insurance, and for which I am solely and completely responsible. I understand that these fees are compliant with Florida Statutes, and that these services may require up to 10 business days to complete. FMLA/Medical Leave/Disability - $25 per page Narrative report - $100 Jury duty letter - $25 Medical records - $1 per page up to 25 pages, and $0.25 cents per page thereafter MD/ARNP follow up visit - $25 Psychotherapy visit - $75 APPOINTMENT CANCELLATION/NO SHOW FEES I understand that I must notify VBH by telephone (office line only, voic is acceptable) of an appointment cancellation at least 24 hours prior to the scheduled appointment time. I understand, agree, and accept that I will be charged as below for a late cancellation (within 24 hours) or if I do not show to my appointment. I understand that this charge is not billable to insurance and that I am solely and completely responsible for this payment.

4 ADMINISTRATIVE AGREEMENT NOTICE OF PRIVACY PRACTICE I acknowledge that I have reviewed the VBH Privacy Practice Form, which is available at the front desk or on PRESCRIPTION POLICY I acknowledge that VBH providers do not perform telephone refills, and that I must be present for a face-to-face visit in order to obtain a medication refill. I understand that it is my responsibility to schedule a follow-up appointment with my provider prior to running out of medication. I understand that auto-refills requested by my pharmacy will be denied, and that any lost prescription for a controlled substance will not be replaced without a police report. I understand that VBH providers do not prescribe narcotic pain medications such as Lortab, Norco, OxyContin, Roxicodone, Vicodin. To replace lost prescriptions, I acknowledge a charge of $10 each. AUTHORIZATION TO RELEASE OR RECEIVE MEDICAL INFORMATION I hereby authorize VBH to release or receive any information necessary to process insurance claims. If I would like to release my medical information to another medical provider, or to a family member or other designated person, I understand that this process involves the completion of a separate form entitled Authorization for Release of Medical Information, which I have access to at any time at MESSAGES/EMERGENCIES/AFTER HOURS CALLS I understand that if I have an emergency, such as suicidal ideation, I should call 911 or go to the nearest ER. For urgent clinical issues such as side effects from a medication, I understand that I may reach the on-call clinician by following the prompts on the main office answering machine. For routine matters, I understand that I can leave a voic message that will be checked the following business day. I understand that I should use phone communication (and NOT ) regarding any clinical concerns, appointments, or medications. CONTINUITY OF CARE & FOLLOW-UP TREATMENT POLICY To ensure adequate medical oversite and practice in accordance with the accepted standard of care, I agree to be seen for all follow-up appointments by my provider at least every 3 months. I understand that if I have not been seen in 4 months, my chart will be closed and will require a new patient appointment in order to re-open. I understand, if the above policies are not adhered to, VBH will not be able to provide my care and I may be discharged from the practice. AUTHORIZATION OF ASSIGNMENT OF BENEFITS I hereby authorize VBH to bill my insurance company directly for services rendered. I authorize payment directly to this practice of any insurance benefits otherwise payable to me. In the event I receive payment from my insurance carrier, I agree to endorse any payment I receive over to Vijapura Behavioral Health for which fees are payable. CONSENT TO TREAT I hereby consent to examination and treatment by a provider at Vijapura Behavioral Health. I hereby affirm that I am of legal age and otherwise competent to consent to medical treatment; or, if not, the person signing below represents the parent, legal guardian or person otherwise allowed by law to consent to the examination and treatment of the patient and by their signature hereto consents. I hereby attest that I have read and understood the information provided to me regarding VBH Policies and Procedures and I agree to abide by these terms and conditions. Practice Policies were last updated June 27, 2017 and are subject to change at the discretion of Vijapura Behavioral Health LLC. Patient s Signature (Responsible Party if Minor): Date:

5 Angela White, ARNP, Ph.D. Patient Name: Authorization to Release or Obtain Health Care Information Birth Date: In order to provide the most comprehensive care, it is important that health care providers collaborate with respect to the individual patient s care. Therefore, I hereby authorize my provider(s) at Vijapura Behavioral Health to: obtain my medical records from, and/or release my medical records to: Provider/Facility Name: Fax: Information Requested: Dates of services: Purpose of Release: Provider/Facility Name: Fax: Information Requested: Dates of services: Purpose of Release: In recognition of the integral role that family and friends play in a patient s mental health care, I hereby authorize my provider(s) at Vijapura Behavioral Health to speak with the following individuals regarding my health: Family/friend Name(s): Phone Number(s): The purpose of this authorization is to improve the quality of my mental health evaluation or treatment. I understand that I am under no obligation to sign this form. I am aware that my records may contain information related to mental health, substance abuse and sexually transmitted diseases (including test results related to HIV/AIDS), and I specifically authorize the release of such information pursuant to this Authorization. This authorization is valid for 1 year from the date signed. I understand that I may revoke it at any time by sending a written, signed, and dated notification to the office address listed above. I understand that any such revocation will not apply to any information already released under this Authorization. Signature of Patient or Legal Representative Date

PATIENT REGISTRATION (Please Print) Social Security # Address City State Zip. Address

PATIENT REGISTRATION (Please Print) Date Name (Last) (First) (MI) Clinician Social Security # Address City State Zip Email Address Home Phone ( ) Mobile/Alt. Phone ( ) Work Phone ( ) PLEASE IDENTIFY WHICH