Lynn Hutchins Psychiatric Nurse Practitioner, PLLC

Similar documents
Chong S Kim, MD ENT and Facial Plastic Surgeon

PATIENT REGISTRATION

Advanced Diabetes & Endocrine Medical Center, P.A.

PATIENT INFORMATION NOTICE OF PRIVACY POLICY PATIENT ACKNOWLEDGEMENT

Patient / Guarantor Information. Spouse / Parent / Other Information. Insurance. Date:

PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:

Caritas Medical Center, LLC

Georgia Foot & Ankle

PATIENT REGISTRATION FORM

Gary W. White, M.D. Dean A. Cione, M.D. Jeremy S. Carrasco, M.D. Ramsey A. Stone, M.D

SUMON NANDI, MD NEW ENGLAND BAPTIST HOSPITAL 125 PARKER HILL AVENUE FOGG BUILDING, SUITE 501 BOSTON, MA 02120

If you are prescribed any medications, where would you like the script sent? Pharmacy Name: Pharmacy Phone:

PAYMENT POLICY: Payment or partial payment is required on the day of visit.

Gentle Family & Cosmetic Care. Raj Zanzi, DMD WELCOME. Insiya Zanzi, DDS

Patient Registration Form

Orthopaedic Specialists, P.L.L.C. PATIENT INFORMATION

Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip

WELCOME TO OUR PRACTICE! We look forward to seeing you very soon.

Address. City/State/Zip. Marital Status: S M D W Sex: M F Date of Birth / / Age. Primary Phone Secondary Phone. Employer PARENT/GUARDIAN

Brian D. Haas, M.D., PL PATIENT INFORMATION

Patient Registration Form This form is posted on our website

PATIENT INFORMATION FORM - DIABETES

Endocrinology of the Rockies, PC. PATIENT REGISTRATION FORM E. 9th Ave. Ste. 245, Denver, CO 80220

LOGO. Financial Policy

Louis Arno, MD, FACP, FCCP Nehal L. Mehta, MD, FCCP, D,ABSM Prashant B. Patel, MD, MS

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

Family Physicians of Johnson City 303 Med Tech Parkway, Suite 100 Johnson City, TN 37604

PATIENT HISTORY FORM. DOB: Age: Male Female Marital Status. Address: Preferred Method of Contact: Home Cell Work Text

PATIENT REGISTRATION FORM CAROLINA EAR, NOSE & THROAT

CENTER CITY DERMATOLOGY STEPHEN HESS, M.D., Ph.D. MEDICAL HISTORY

PATIENT REGISTARTION

Prefix Last First Middle Suffix. Maiden Gender SSN Marital Status Date of Birth

Welcome to Family Tree Dental Care Midway Rd., Ste 106A Farmers Branch, TX 75244

Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): Circle: MALE or FEMALE Married Status: Social Security: - -

Please bring the medications you are currently taking. If you had x- rays made, please bring the films with you when you come to the office.

REGISTRATION FORM. Physician (PCP): PATIENT INFORMATION. Last Name: First Name: MI: Billing Address: City: ST Zip Code:

Laguna Woods Dermatology

Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer

Delaware Heart & Vascular, P.A.

2018 REGISTRATION FORM HIGHLIGHTED AREAS REQUIRED (Please Print Clearly)

Phone: (512) Fax: (512)

Green Hills Plastic Surgery Stephen M. Davis, MD, FACS

Patient Information Form

PATIENT REGISTRATION FORM

Other Scan(s): List All Your Medical Diagnosis: Chemotherapy? YES NO If yes, please list treatment regimen:

TEXAS MEDICAL & SLEEP SPECIALISTS, PLLC REGISTRATION FORM ADULT

Date: Patient Health Information. Patient Name: First Middle Last Nickname. Date of Birth: Age: Sex: Male Female. Referring Physician:

PRIMARY INSURANCE TO FILE SECONDARY INSURANCE TO FILE

PATIENT INFORMATION SHEET

Name (Last, First, MI): Date of Birth: / /

Green Hills Plastic Surgery Stephen M. Davis, MD, FACS

EYES OF THE SOUTHWEST New Patient Information

Name Date of Birth / / First M.I. Last. Address City State Zip. Home Phone Cell Phone Work Phone. Address

Bellingham Arthritis & Rheumatology Center. 470 Birchwood Avenue, Suite C, Bellingham, WA (P) (F)

ADULT PATIENT REGISTRATION

Patient Name: Please list your medications below. Include the strength and how often you take them.

ERIC ROCKMORE, DPM, FACFAS

PATIENT INFORMATION FORM RICHARD L. MALINICK, M.D. ORTHOPAEDIC SURGERY 1125 Via Verde, San Dimas, CA

We are limited, not by our abilities, but by our vision.

New Patient Registration

TEXAS PEDIATRIC SPECIATLIES AND FAMILY SLEEP CENTER REGISTRATION FORM PEDIATRIC (Please Print) Referring Physician: _ Primary Care Physician: _

PATIENT REGISTRATION

West Cary Family Physicians 256 Towne Village Dr Cary, NC

Welcome to Savannah Psychiatry

Welcome and Thank You For Choosing Pain Specialists of Charleston, P.A.

CINCINNATI PAIN PHYSICIANS, LLC (CPP) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Past Medical History

New Patient Medical Information Survey Revised 3/2013

SILVERDALE EYE PHYSICIANS PATIENT REGISTRATION FORM

Today s Date (mm/dd/yyyy):

Any pertinent medical records

BIRCH BAY DERMATOLOGY

Jamie Gottlieb, M.D. Spinal Surgery PATIENT INFORMATION

Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA

Patient Registration

Our office is located at 501 Darby Creek Road, Suite 21 in Lexington. This is just off Man- O-War Blvd, between Palumbo Drive and Mapleleaf.

Review of Systems (Please check all that apply)

I have read and acknowledge all of the above policies associated with Pioneer Cardiovascular Consultants, PC including: (PLEASE INITIAL)

Chief Complaint Form: Patient Name: Age: DOB: Occupation: Employer: Referring Physician: Town: Primary Care Physician: Town: Y N

***PLEASE PRINT USING BLACK INK ONLY***

Social Security No: Home Phone: _. Employer: Work Phone: _. Employer Address: Occupation: _. Spouse/Parent Name: Phone No: _

SATISH NARAYAN, MD & NISHA SATISH, MD

7541 US HWY 87 E, Suite #1 San Antonio, Texas (210) PATIENT S EMPLOYER PLEASE CIRCLE ONE :

Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax:

TEXAS PEDIATRIC SPECIALTIES AND FAMILY SLEEP CENTER REGISTRATION FORM ADULT

OUR POLICIES. Prior Authorization for prescriptions is $10.00 for each authorization completed.

PRIMARY INSURANCE: Policy # Group # Name of Subscriber (if other than patient)

HEALTH QUESTIONNAIRE NAME SEX AGE DOB HEIGHT WEIGHT PLACE OF BIRTH REASON FOR VISIT

Date of Birth: Age: Social Security #: Address: City: State: Zip Code: Home #: Cell#: Work#: Sex: F or M Marital Status: S M Wid Sep Div

PATIENT INTAKE AND MEDICAL INFORMATION

Anthem Hills Dental PATIENT INFORMATION

Consent For Treatment

PATIENT REGISTRATION

New Patient Registration Information

Name: Date of Birth: First Middle Last Residence: Street City Zip Code Home Phone Number Social Security: - -

Essex-Hudson Urology

West Houston Infectious Disease Associates. Address: Number Street Apt. No. City State Zip. Home Phone: Cell: Work:

CHIROPRACTIC 1 ST NEW PATIENT INFORMATION PATIENT INFORMATION

Local Address: City State Zip. Permanent Address: City State Zip. Secondary Insurance Co: Insurance Phone: Policy #:

GIVE US STRENGTH PHYSICAL THERAPY

Transcription:

We look forward to working with you and getting to know you! It is our goal to provide the best mental health care, as well as making your visits here pleasant, courteous and as efficient as possible. Our normal office hours are Monday through Thursday, 8:00 am to 5:00 pm. We are closed for lunch from noon until 1:00. Please remember to bring your current insurance cards and co-payments with you to your visit. All co-pays and deductibles are due at the time of service. Patients that do not bring their co-pay or insurance card will be rescheduled. If for some reason your account falls into collection for non-payment, you will be responsible for your outstanding balance and any additional collection agency fees. We accept Visa, MasterCard, and American Express for credit or debit and also accept cash or check. If a check is returned due to insufficient funds, a processing charge of $50.00 will be charged to your account for the returned check. Our office does charge a fee for completing medical forms and for personal record requests. $10.00 per page Personal record requests -.75 per page first 25 pages,.50 pages 26-100 (minimum request of $10.00) Narrative summary/letter - $25.00-$100.00 Forms/letters are done as a courtesy and may take up to 30 days to complete. If for any reason you are unable to make your scheduled appointment, please call our office at 252-281-5044 24 hours prior to your visit. Missed appointments without 24 hours advance notice will be charged $75.00, payable before patient's next visit. For prescription refills, please include the phone number of your pharmacy and your date of birth or call your pharmacy and they will contact our office. Please allow 24 hours for regular prescription refills and 48 hours for all stimulant (medication for ADHD) prescription refills. Stimulant prescriptions must be picked up at the office. You may contact our office with questions, concerns or prescription refills by calling 252-281-5044 or by emailing us at contact@lynnhutchinspsych.com and all efforts will be made to respond by the end of the day or at least within 24 hours. Consent for External Prescription Check I hereby grant permission to view my prescription history from external sources. In case of psychiatric emergency after hours or on the weekends, please call 252-292-5371 or call 911 for transport to your nearest emergency room. No refills will be given after hours or on weekends. For non-emergent issues, we ask that you call during regular office hours; otherwise, there will be a $35.00 charge billed to you. Our web page, lynnhutchinspsych.com, is an easy way to stay updated on closings due to holidays, vacation, or inclement weather which is important to ensure refills are prescribed to prevent running out of medication when the office is closed for extended periods of time. Please note that the office is always closed for a week during the Fourth of July holiday and December 24 through January 1. Please make sure you have enough medication to last during these periods of time. If you do run out, your primary care provider may or may not refill the medication until the office re-opens. Once again, welcome to. We look forward to establishing a lasting relationship as your mental health provider. Patient Name: Signature: Date: Witness: Patient Copy

We look forward to working with you and getting to know you! It is our goal to provide the best mental health care, as well as making your visits here pleasant, courteous and as efficient as possible. Our normal office hours are Monday through Thursday, 8:00 am to 5:00 pm. We are closed for lunch from noon until 1:00. Please remember to bring your current insurance cards and co-payments with you to your visit. All co-pays and deductibles are due at the time of service. Patients that do not bring their co-pay or insurance card will be rescheduled. If for some reason your account falls into collection for non-payment, you will be responsible for your outstanding balance and any additional collection agency fees. We accept Visa, MasterCard, and American Express for credit or debit and also accept cash or check. If a check is returned due to insufficient funds, a processing charge of $50.00 will be charged to your account for the returned check. Our office does charge a fee for completing medical forms and for personal record requests. $10.00 per page Personal record requests -.75 per page first 25 pages,.50 pages 26-100 (minimum request of $10.00) Narrative summary/letter - $25.00-$100.00 Forms/letters are done as a courtesy and may take up to 30 days to complete. If for any reason you are unable to make your scheduled appointment, please call our office at 252-281-5044 24 hours prior to your visit. Missed appointments without 24 hours advance notice will be charged $75.00, payable before patient's next visit. For prescription refills, please include the phone number of your pharmacy and your date of birth or call your pharmacy and they will contact our office. Please allow 24 hours for regular prescription refills and 48 hours for all stimulant (medication for ADHD) prescription refills. Stimulant prescriptions must be picked up at the office. You may contact our office with questions, concerns or prescription refills by calling 252-281-5044 or by emailing us at contact@lynnhutchinspsych.com and all efforts will be made to respond by the end of the day or at least within 24 hours. Consent for External Prescription Check I hereby grant permission to view my prescription history from external sources. In case of psychiatric emergency after hours or on the weekends, please call 252-292-5371 or call 911 for transport to your nearest emergency room. No refills will be given after hours or on weekends. For non-emergent issues, we ask that you call during regular office hours; otherwise, there will be a $35.00 charge billed to you. Our web page, lynnhutchinspsych.com, is an easy way to stay updated on closings due to holidays, vacation, or inclement weather which is important to ensure refills are prescribed to prevent running out of medication when the office is closed for extended periods of time. Please note that the office is always closed for a week during the Fourth of July holiday and December 24 through January 1. Please make sure you have enough medication to last during these periods of time. If you do run out, your primary care provider may or may not refill the medication until the office re-opens. Once again, welcome to. We look forward to establishing a lasting relationship as your mental health provider. Patient Name: Signature: Date: Witness: Office Copy

Patient Information Please Print Patient Name Date of Birth Gender M F Mailing Address City State Zip Home Phone Work Phone Cell Phone Preferred number for reminder call: (Circle one) Home Cell Work May we leave a message: Y N SSN Email Address Emergency Contact Phone Relationship School/ Employer Grade If Patient is not Responsible Party, who is responsible for payment? Name Mailing Address City State Zip Relationship Phone Policy Holder Name DOB / / Policy Holder Address Policy Holder s Relationship to the Patient Insurance Company Name Subscriber # Ins. Co. Mailing Address Group # City State Zip Pharmacy Name Phone Please remember that insurance is considered a method of reimbursing the patient for fees paid to the provider, but is usually not designed to pay the entire fee. Because insurance companies vary in the amount they will pay for various services, it is ultimately your responsibility to pay the portion of the bill not paid by your insurance company (unless otherwise restricted by law or agreement we might have with insurer). ALL CO-PAYS AND DEDUCTIBLES ARE DUE AT THE TIME OF SERVICE. I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier of any other commercial insurance company, and original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply. Signature Date

Health History Name: Date: Indicate (Y) for yes and (N) for no for the following: Have you recently had: Fever Weight Loss Blurred Vision Sore Throat Sinus Problems Chest Pain Palpitations Shortness of Breath Wheezing Asthma Diarrhea Abdominal Pain Urinary Problems Sexually Transmitted Disease Weakness Diabetes Bleeding Bruising Muscle Pain Heat-Cold Intolerance Seizures Dizziness Depression Anxiety Rash What is the reason/medical problem for your visit? How long have you had the problem? Does anything cause the problem or make it worse? What medication do you take now? Do you have any pain? Rate the pain 1-10 Signature of Patient

Notice of Privacy Practices I,, have read and understand the Privacy Practices of Lynn Hutchins Psychiatric Nurse Practitioner, PLLC. I am aware that if I don t cancel my appointment at least 24 hours ahead of time, I will be charged a fee of $75.00. I authorize to provide medication management and psychotherapy as needed. I am giving my written consent for screening, treatment, evaluation, and medication. Date Patient Signature Witness Signature of Patient s Legal Representative A copy of privacy practices was made available for the patient to read, but a signature was unable to be obtained because: Patient refused to sign Emergency situation

Controlled Substance Contract Some of the medications commonly prescribed in this office are controlled substances and can be addictive, such as benzodiazepines (Klonopin, Xanax, Valium, Ativan) and stimulants (Adderall, Ritalin). It is important that these medications be used responsibly. I,, understand and voluntarily agree that (initial each statement after reviewing): I am responsible for my medicines. I will keep the medicine safe, secure and out of the reach of children. If the medicine or prescription is lost, stolen or is used up sooner than prescribed, I understand that it will not be replaced until it is due for refill (30 days from when last filled). I will take my medication as instructed and not change the way I take it without first talking to Lynn. I will not sell my medicine or share it with others. I will not call at night or on the weekends to ask for refills. I understand that refill requests will be made during office hours only. I will tell Lynn all other medicines that I take, and let her know if I have a prescription for a new controlled substance from another provider. I will only use one pharmacy to get my controlled medications filled. I agree to give a blood, saliva, and/or urine sample, if asked, to test for drug use. I understand that I may lose my right to treatment in this office if I break any part of this agreement. Patient Name: Signature: Date: Witness:

2024 © financedocbox.com Privacy Policy | Terms of Service | Feedback