Psychological Services, P.C. (Comprehensive Psychiatric & Psychological Services) PSYCHIATRY Raja Rao, MD PSYCHOLOGY Robert J. Maiden, PhD Laura A. DeMarco, PhD Cynthia Dodge, PsyD Terry Taggart, PsyD Lynn O Connell, PsyD John Cerio, PhD NURSE PRACTITIONER Kim Peckham, FNP, NPP in Psychiatry 15 Pleasant St Linden Oaks Therapy Offices Hornell, NY 14843 100 Linden Oaks, Ste 200 P(607) 324-9240 Rochester, NY 14625 F(607) 324-9744 P(585) 586-1600 (directions) P(607) 324-9240 (appointments) 2438 Constitution Ave 112 Park Ave Olean, NY 14760 Wellsville, NY 14895 P(716) 372-9344 P(585) 593-1859 F(607) 372-9497 F(585) 593-5463 Note to new clients: Dr. Rao has agreed to see you for an initial evaluation. An initial evaluation does not guarantee that you will be accepted as a patient. Dr. Rao will decide how to proceed after this consultation, and based on his findings, a treatment plan will be developed. This includes, but is not limited to; the acceptance as a new patient, referral to another provider within or out of Milestone. Printed Name Signed Name
MILESTONE PSYCHIATRIC & PSYCHOLOGICAL SERVICES, P.C. 15 Pleasant St Hornell NY 14843 (607)324-9240 fax (607)324-9744 112 Park Ave Ste 2 Wellsville NY 14895 (585)593-1859 fax (585)593-5463 2438 Constitution Ave Olean NY 14760 (716)372-9344 fax (716)372-9497 LOTO 100 Linden Oaks Ste 200 Rochester NY 14625 (607) 324-9240 fax (585)586-7951 Authorization for Release of Confidential Information Patient Name: of Birth / / Authorize at Milestone PPS, PC: 15 Pleasant St. Hornell, NY 14843 release information to: obtain information from: exchange information with: Person/organization receiving/communicating the information: Name: Address: Phone: Fax: Description of Information to be received/disclosed (check all that apply): Psychological/social assessment Medical history Psychiatric evaluation Lab/radiology reports Treatment plans Juvenile/justice records Progress notes Social services records Discharge summaries Verbal communication Subpoena or legal process Written communication Worker s Compensation Claim Other Disability Claim The dates records to be disclosed / / TO / / ALL Purpose of release: evaluation continuity of care medication history other One Time Use/Disclosure: I authorize the one-time use or disclosure of the information described above to the destination identified herein. My authorization will expire: When acted upon 90 days from this date Other: Periodic Use/ Disclosure: I authorize the periodic use or disclosure of the information described above to the destination identified herein. My authorization will expire: When I am no longer receiving services from above identified person/ organization/ facility/ program One year from the date signed Other: I understand that this authorization is voluntary. Prohibited Disclosure: I understand that my health information may be protected by the Federal Regulations for Privacy of Individually Identifiable Health Information (Title 45 if the Code of Federal Regulations, Parts 160, and 164) For Alcohol and Drug Abuse this information is protected by federal l confidentiality rules (42 CFR, Part 2). The federal rules prohibit making any consent of the person to whom it pertains or as otherwise permitted by 42 CFR, Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. I understand that I may revoke this consent at any time except that action has been taken in reliance on it (e.g. probation, parole, etc) and that in any event this consent expires automatically as described above. I also understand that I may inspect and upon payment of the usual fee, receive a copy of the released information and I may receive a copy of this consent form. (A copy or facsimile of this authorization shall be as valid as the original). PROHIBITION ON CONFIDENTIALITY: I understand mental/physical health professionals and teachers must report child sexual/physical abuse and neglect, threats of suicide and threats of bodily harm to others. Signature Parent/Guardian Witness Relationship to patient
Psychological Services, P.C. (Comprehensive Psychiatric & Psychological Services) PSYCHIATRY Raja Rao, MD PSYCHOLOGY Robert J. Maiden, PhD Laura A. DeMarco, PhD Cynthia Dodge, PsyD Terry Taggart, PsyD Lynn O Connell, PsyD John Cerio, PhD NURSE PRACTITIONER Kim Peckham, FNP, NPP in Psychiatry 15 Pleasant St Linden Oaks Therapy Offices Hornell, NY 14843 100 Linden Oaks, Ste 200 P(607) 324-9240 Rochester, NY 14625 F(607) 324-9744 P(585) 586-1600 (directions) P(607) 324-9240 (appointments) 2438 Constitution Ave 112 Park Ave Olean, NY 14760 Wellsville, NY 14895 P(716) 372-9344 P(585) 593-1859 F(607) 372-9497 F(585) 593-5463 Linden Oaks Patients Payment for services can be made as follows. - CASH: you may pay with cash at the time of service and Dr. Rao will give you a receipt. - CHECK: you may pay by check at the time of service, or mail a check to: Milestone PPS, PC 15 Pleasant St Hornell, NY 14843 ***please make checks payable to Milestone PPS, PC*** - CREDIT CARD: you may pay with Visa or Mastercard by calling the main office directly at 607-324-9240 Monday-Thursday 8am-5pm.The patient copy will be mailed the same day.
Psychological Services, P.C. (Comprehensive Psychiatric & Psychological Services) PSYCHIATRY Raja Rao, MD PSYCHOLOGY Robert J. Maiden, PhD Laura A. DeMarco, PhD Cynthia Dodge, PsyD Terry Taggart, PsyD Lynn O Connell, PsyD John Cerio, PhD NURSE PRACTITIONER Kim Peckham, FNP, NPP in Psychiatry 15 Pleasant St Linden Oaks Therapy Offices Hornell, NY 14843 100 Linden Oaks, Ste 200 P(607) 324-9240 Rochester, NY 14625 F(607) 324-9744 P(585) 586-1600 (directions) P(607) 324-9240 (appointments) 2438 Constitution Ave 112 Park Ave Olean, NY 14760 Wellsville, NY 14895 P(716) 372-9344 P(585) 593-1859 F(607) 372-9497 F(585) 593-5463 Client: Last Name First Name Middle Initial DOB: / / Social Security # - - Sex: M F Address: PO Box Street City State Zip Code Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Can we leave a message? YES NO Can we leave a message? YES NO Can we leave a message? YES NO Employer: Student: Not Employed: Primary Care Physician: Phone: Pharmacy Name/ Phone: Emergency Contact: Relationship to patient: Phone:
Patient Name: DOB: Presenting Problem: What is the main concern that leads you to consult us? Psychiatric and Psychological History: Provide all past mental health and substance abuse treatment, including outpatient and inpatient. Medication History: List all current and past psychiatric medications: DRUG DOSE FREQUENCY PRESCRIBING PHYSICIAN List current medications other than psychiatric: DRUG DOSE FREQUENCY PRESCRIBING PHYSICIAN List any non-prescription medications: Medical and Surgical History Past/Present Social History Marital status: Single Married Widowed Divorced Separated Partnered Name: Children Name Age Location Custody (Joint/ Single, etc) Pertaining to children who will be seen: Lawyer: phone: Law Guardian: phone: School Counselor: phone:
Psychological Services, PC Patient Name: DOB: Financial Policy We are dedicated to providing the best possible care for you, and we want you to completely understand our payment policies. 1. Insurance: We participate in most insurance plans, including Medicare. If you are insured by a plan we do business with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. 2. Co-payments and Deductibles: All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. For your convenience we accept MasterCard and Visa. You will be billed a $10 handling fee for not paying your co-pay at the time of service unless other arraignments have been made. 3. Non-covered Services: Be aware that some and perhaps all of your services you receive may be non-covered or not reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of your visit. 4. Proof of Insurance: All patients must complete out patient registration form before being seen. We must obtain a copy of your current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in time to meet your insurance company claim filing limit, you will be responsible for the balance of the claim. 5. Claims Submission: We will submit your claims and assist you in any way we reasonably can to help you get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. 6. Coverage Changes: If your insurance changes, please notify us so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. 7. Non-payment: If your account is over 30 days past due, you will receive a letter stating that you have 30 days to pay your account in full. Partial payment will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternate medical care. 8. NO SHOW Fees: The number of patients requiring services dictates the use of time responsibly. Please be advised of the institution of a no show fee for failure to come to a scheduled appointment without at least 24 hours prior notice with the exception of an emergency. This fee cannot be billed to an insurance company and is due prior to your next appointment. We reserve the right to not reschedule future appointments. PsyD/ PhD $40 (20-30 min)/ $80 (37-50 min) MD/ FNP $50 Milestone Psychiatric &
Psychological Services, PC Patient Name: DOB: Professional Fees The fee for an initial visit is $230. Subsequent 37-50 minute sessions are $166, and 20-30 minute sessions are $103, and medication management visits are $92. You may be eligible for a sliding-scale self-pay rate, please inquire with the receptionist. Professional services that you may request and/or require, including written reports, consultation with other professionals (with your informed consent), and telephone, fax, and/or e-mail communications which become excessive and beyond the scope of reasonable services, will be billed at $161.25/hour accrued in 15 minute intervals. If you become involved in legal proceedings that require participation, you will be expected to pay for all professional time, including preparation, travel, and attendance at any legal proceeding. Due to the complexity of legal proceedings and time away from client hours, the hourly rate is $215, accrued in 15 minute intervals. Occasionally, it may be advisable to administer self-report rating scales and/or other social-emotional and psychological measures. You should be aware that your insurance company may not cover the cost for the administration and scoring of these assessment measures. In addition, psycho educational assessments may not be covered by your insurance company. Rates for these types of psychological testing are generally $174.00 per unit. Specifics and financial arrangements should be discussed prior to service. Our practice is committed to providing the best treatment to our patients. Our fees are representative of the usual and customary charges for our area. Let us know if you have any questions or concerns. I have read and understand the Financial Policy and Professional Fees and agree to abide by these guidelines: Signature of patient (or responsible party, if minor) Prescription Refill Policy When you have a prescription that needs to be refilled, please do the following: 1. Please call the office at least 7-10 days in advance. Failure to do so may result in you not getting your prescriptions filled in a timely manner. ALL prescriptions need approval from Dr Rao/ Kim Peckham before they can be obtained. 2. Please have all applicable information ready for the receptionist when calling (prescription name, pharmacy, etc). Signature of patient/ responsible party
Psychological Services, PC Patient Name: DOB: Informed Consent for Treatment Clinical records are kept under the strictest rules of confidentiality, which means that information about your treatment will not be releases to any outside agency or individual without your written permission. Please be advised, however, that rules of confidentiality will be broken under certain circumstances as described in the NOTICE OF PRIVACY PRACTICES below. Please do not hesitate to ask questions. Entering mental health treatment is a courageous step. You should know that sometimes symptoms become worse before they become better, though this should subside as the work of treatment progresses. You may be asked to participate in activities and tasks outside the sessions held here. While you have the right to refuse any therapeutic technique, we must be able to discuss your thoughts and feelings about treatment. You will be involved in the process of designating and implementing, and the periodic review, of your treatment plan. You have the right to be informed of your mental health diagnosis after the mental health assessment is completed, and the purpose of any prescribed medication and potential side effects. You also have the right to withdraw consent and terminate services at any time. If you have any questions about the nature if your treatment, talk directly to the doctor you are seeing as soon as the question arises. I authorize Milestone PPS, PC to release given info to my listed insurance company, information from my records relating to the identity, diagnosis, and treatment for the purposes or needs of payment. Signature of patient/ responsible party HIPAA I have reviewed the HIPAA privacy statement. Signature of patient/ responsible party