COMPLETE, SIGN AND RETURN THIS ENTIRE PACKET OF INFORMATION PLEASE MAIL TO OFFICE AFTER COMPLETION DO NOT FAX 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. To our New Patients, Thank you for choosing our practice! We are committed to the success of your mental health and care. Enclosed you will find forms which must be completed, signed and returned to our office. receive these forms back, we will call you to schedule an appointment. Once we For your convenience, we have answered a variety of commonly-asked financial policy questions below. We believe that a good relationship is based on understanding and open communication. Our staff has been instructed to make every effort available to you to clarify any misunderstanding you have concerning your balance and payment of your bill. If you need further information about any of these policies, please ask to speak with our Office Manager. How May I Pay? We accept payment by cash or check and credit cards in office. For your convenience, our billing office is staffed Monday through Friday from 9:00 AM to 4:30 PM. The phone number is (859) 263-9305. We will bill your insurance for you; however, you are expected to pay your co-pay/deductible at the time of your visit. Please contact our Office Manager if your address or insurance information changes. There is a check return fee of $30.00. Insurance: VERY IMPORTANT---PLEASE READ THIS PARAGRAPH!!! It is extremely important that you check the mental health benefits portion of your insurance policy PRIOR TO YOUR APPOINTMENT. Be aware of any restrictions or limits on your policy including any pre-authorization requirement. Some insurance companies require preauthorization which means that you have to call your insurance company before your visit and they will give you a prior authorization number. You will need to bring this number with you to your visit. If you fail to bring this number with you, you will not be seen that day and will be charged a missed new appointment fee of $30.00. This fee is due before you will be rescheduled and is not covered by insurance. Do not forget to bring your insurance card to the first appointment and be prepared to pay any out of pocket expenses (i.e. Deductible, Co-pay, and Co-insurance) by our next appointment. We file all primary and secondary insurance claims regardless of whether we are under contract with that insurer. It is, however, your responsibility to know the benefits and requirements of your policy. When is my account delinquent? An account is considered past due 60 days following billing unless other arrangements have been made. Unpaid accounts beyond 90 days are considered delinquent and may be forwarded to our collection agency. How are my Medicine Refills handled? Our policy is for the patient to call their pharmacy and ask them to fax the request for your medication to (859) 264-1169. Requests are usually handled within 48 business hours. If you are running short on your medication due to having to reschedule an appointment or missing one, there will be an $8.00 charge. Processing times may vary depending on the availability of your doctor, who for your safety must review each request prior to completion. Page 1
Are there Service Charges? If the decision is made to see a patient who does not have his/her co-pay or deductible, a service charge of $25 will be added. Your insurance company will be notified in writing that this occurred which would result in a loss of insurance. Is Interest Charged? Patients with an outstanding balance over 60 days will be charged interest of 12%. What Is My Financial Responsibility for Services? Claims that have not been paid in 60 days will be automatically billed to you and we can assist you in refilling your insurance at your request. What about missed appointments? We would appreciate your help and courtesy of a call if you are unable to keep an appointment. Please notify our office at least twenty-four (24) hours prior to the appointment time or you will be charged a missed appointment fee of $30 which is due before you will be seen for your next visit. Three (3) non-cancelled/rescheduled, missed appointments are grounds for patient discharge. What if My Child Needs to See the Physician? A parent or legal guardian must accompany patients who are minors on the patient's first visit. This accompanying adult (who consents to the treatment) is responsible for payment of the account, according to the policy outlined on the previous pages. We will not be involved in separation/divorce disputes. I have read, understand, and agree to the above Financial Policy. I understand that charges not covered by my insurance company, as well as applicable co-payments and deductibles, are my responsibility. I authorize my insurance benefits be paid directly to Andre N. Fernandez, M.D. I authorize Andre N. Fernandez, M.D. to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim. Printed Name Date Signature Relationship Page 2
(3) CONSENT TO TREAT I hereby authorize and consent for André Fernandez, MD, to provide medical and/or psychiatric treatment and/or diagnostic procedures for: Patient Name Date of birth I hereby authorize my insurance companies to pay directly to André Fernandez, MD all insurance payments for services rendered and otherwise payable to me. I authorize André Fernandez, MD, to release any information to my insurance that is necessary in order to process my insurance claims. companies I hereby accept responsibility for any/all portions of the bill not covered or paid by my insurance including, but not limited to: charges for treatment given with my permission, (even when not authorized by my insurance company) any deductibles, co-pays or coinsurance, as well as any reasonable collection fees. I agree to pay all applicable payments AT THE TIME OF SERVICE. CANCELLATION POLICY: I understand that 24 hours notice is required for cancellation of any appointment or I will be billed $30.00 for that visit. I also understand that my insurance will not pay for any no-show or late cancellation. I HAVE READ AND ACCEPT ALL TERMS AS LISTED ABOVE. DATE AUTHORIZING SIGNATURE The signature above is (check one): Patient Parent Legal Guardian Other (Explain) Page 3
(4) PATIENT RESPONSIBILITY Patient name: Date of birth I,, being the patient or responsible party for the patient, understand it is my responsibility to see that any medication prescribed by Dr. Fernandez is to be used only as directed. If I should administer medication in any way other than as prescribed, I will accept full responsibility for any problem that may arise as a result of this change from the directions I was given. I also understand and agree to be responsible for the physical safety of any and all medications prescribed and I hereby relieve Dr. Fernandez of any liability for my actions. Signed Date Relationship to patient: Self Parent Legal Guardian Other (Explain) Witnessed by: Page 4
HIPPA CONSENT I give the practice/clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews. I have been informed that I may review the practice/clinics Notice of Privacy Practice (for more complete description of uses and disclosures) before signing this consent. I understand that this practice/clinic has the right to change their privacy practices and that I may obtain my revised notices at the practice. I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice/clinic is not required to agree to the request. If the practice agrees to my requested restrictions, they must follow the restrictions. I also understand that I may revoke the consent at any time by making a request in writing, except for information already used or disclosed. Signature: Date: Patient or Legal Guardian If signed by patient representative, state the relationship of patient Page 5
(5) REGISTRATION INFORMATION (PLEASE PRINT) Date Home Phone Patient Social Security Address City State Zip Sex M F Age Date of birth Single Married Separated Divorced Who is responsible for this account Relationship to the patient Address (if different) City State Zip Name Social Security Employer s Name & Address Occupation Business Phone Spouse (of responsible party) Social Security Employer s Name & Address Occupation Business Phone Purpose of visit Name of Primary Insurer ID # Group # Date of birth Name of Secondary Insurer ID # Group # Date of birth Medicare Medicaid ID # In case of emergency, who should be notified? Name of Pharmacy Phone How did you learn of our Practice? ASSIGNMENT OF INSURANCE BENEFITS The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/of dependants. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependants, and that I will be bound by this signature as though the undersigned had personally signed the particular claim. I hereby authorize to pay and hereby assign directly to (Name of Insured) (Name of Insurance Company) Dr. Andre N. Fernandez all benefits, if any, otherwise payable to me for his/her services as described on the attached forms. I understand I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits, when received by and paid to Dr. Andre N. Fernandez will be credited to my account, in accordance with the above said assignment. (Authorized Signature of Subscriber) (Insured s DOB) (Date) Page 6
(6) ADULT / INTAKE HISTORY FORM Name Date of birth Age Phone ( ) Employer Position Place of birth List all persons who live in the household Social Security # Name Age Relationship Occupation What are the main reasons or problems that caused you to set up this appointment? List any known previous diagnosis given Who is your current counselor (Please provide name, address, phone)? When was your first visit? Last visit? # of visits in last 2 months? Do you want me to send a regular report to the counselor after your visit with me? Yes No ALLERGIES to medications What medicines do you take now (list below)? For additional medications, use reverse side of this paper. Name Dose Direction How well does it work? Prescribing Doctor (Name, address) Page 7
(7) ADULT / INTAKE HISTORY FORM What type of doctor is this? Psychiatrist Family Practice Neurologist Other When was the last time you saw this doctor? What medications have you taken before that were stopped? Name Dose How often? Why was it stopped? Have there ever been any problems with prior treatment? Who is your current physician (Please provide name, address, phone)? When was your last visit? # of visits in last 2 months? Do you want me to send a regular report to this physician after your visit with me? Yes No Date of last hearing test? Date of last vision test? Date of last physical exam? Results: Results: Results: Have you ever had to stay overnight in a hospital? Yes What other medical problems have you had in the past? Current medical symptom checklist (please give details) No Why? Headaches Y / N Diarrhea Y / N Dizzy Spells Y / N Blurry Vision Y / N Stomach Pains Y / N Bladder Problems Y / N Nausea / Vomiting Y / N Chest Pains Y / N Bowel Problems Y / N Weakness Y / N Heart Problems Y / N Seizures Y / N Breathing Problems Y / N Other Page 8
(8) ADULT / INTAKE HISTORY FORM Date of last menstrual cycle Do you use birth control? How many times have you been married? Sexual abuse? Y / N Have you ever been a victim of physical abuse? Y / N Have you ever used any drugs? Y / N Alcohol? Y / N Have you ever tried to cut back? Y / N Have you ever thought you had a learning disorder or problems in school? Y / N Last grade completed? Did you ever receive any special education in school? What other medical problems do you have? What nervous disorders (see below) have been suspected or are getting treated in your: Biological brothers or sisters: Mother: Mother s Parents (your grandparents): Mother s brother / sister (your uncles / aunts): Father: Father s Parents (your grandparents): Father s brother / sister (your uncles / aunts): Y / N Nervous Disorders: A. Depression H. Psychosis O. Manic Depression B. Anxiety I. Hallucinations P. Bipolar Disorder C. Nerves J. Drug Problems Q. Twitches or tics D. Schizophrenia K. Mental Retardation R. Psychiatric Hospital E. Chemical Imbalance L. Learning Disorder S. OCD F. Epilepsy M. Suicide Attempts T. Disability G. Seizures N. Death By Suicide Answer the following questions from JUST THE PAST 6 MONTHS: How long does it usually take you to fall asleep at night? How many hours of sleep per night do you average? Do you have problems waking up early? Y / N Are there financial problems? Y / N Current stressors: How will you tell if the treatment we start is working? _ What other questions do you have? Page 9
Date Name ANDRÉ N. FERNANDEZ, MD, P.S.C. 9) MOOD DISORDER QUESTIONNAIRE Instructions: Please answer each question as best you can. Date of birth 1. Has there ever been a period of time when you were not your usual self and YES NO you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? you were so irritable that you shouted at people or started fights or arguments? you felt much more self-confident that usual? you got much less sleep than usual and found you didn t really miss it? you were more talkative or spoke much faster than usual? thoughts raced through your head or you couldn t slow your mind down? you were easily distracted by things around you that you had trouble concentrating or staying on track? you had much more energy than usual? you were much more active or did many more things than usual? you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? you were much more interested in sex than usual? you did things that were unusual for you or that other people might have thought were excessive, foolish or risky? spending money got you or your family in trouble? 2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? 3. How much of a problem did any of these cause you like being able to work; having family, money or legal troubles; getting into arguments or fights? Please circle one response only. No problem Minor problem Moderate problem Serious problem 4. Have any of your blood relatives (i.e. children, sibling, parent, grandparent, aunt, uncle) had manic-depressive illness or bipolar disorder? 5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? Page 10