Patient Registration Satish Narayan, MD Nisha Satish, MD Humaira Khalid, MD Vivian Kisanga, NP Dominique Wilson, NP : / / Acct. # Patient Name: Last First Middle Initial Preferred Name (nickname) SS#: - - Gender: Female / Male of Birth: / / Age: Home Address: City: State: Zip Code: Home Phone: ( ) Cell phone/alternate number: ( ) Email Address: Marital Status: Single / Married / Divorced / Separated / Widowed Employed: Yes / No Full Time Student: Yes / No Disabled: Yes / No Retired: Yes / No Employer: Occupation: Address: Wk. Phone: ( ) ext. **************************************************************************************Emerge ncy Contact: Relationship: Phone: ( ) Primary Care Physician: Phone: Pain Specialist: Phone: Neurologist: Phone: Pharmacy: Phone: Counselor: Phone: ************************************************************************************** Spouse s Name: Spouse s of Birth: / / Last First Spouse s Employer: Spouse s Work Phone: ( ) ext. Spouse s SS#: - - ************************************************************************************** Is Patient a Minor? Yes No **IF YES, PARENT / GUARDIAN MUST FILL OUT** Parent Name: of Birth: / / Last First Address: City: State: Zip Home Phone: ( ) Social Security#: - - Employer: Work Phone: ( ) ext. Relationship to patient: May we contact you by phone for appointment reminders? Home: Yes No Work: Yes No / / Signature of Patient / Parent / Guardian **IF PATIENT IS A MINOR, PARENT OR GUARDIAN MUST SIGN**
Psymed Solutions Office Policies Appointments: (initial) Our office hours are 9:00am to 5:00pm Monday through Friday. However, at this time our office does not see patient s on Fridays. Patient appointments are scheduled by calling during regular office hours. Financial Policy: (initial) An estimated payment is due at time of service by cash, money order, Visa, MasterCard, Discover, or American Express. Depending on the level of service provided there may be an additional fee that is patient responsibility to pay within 30 days of receipt of your statement. Patients are responsible for their co-payments and/or deductibles and coinsurance at the time services are rendered for patients on Preferred Provider Plans (PPO s) or Health Maintenance Organizations (HMO s). Any balance on an account that is greater than 30 days old is considered past due. A statement will be mailed on a monthly basis and will reflect the current balance for all services rendered prior to the date on the statement. Payment is due upon receipt of statement. Insurance: (initial) Your insurance policy is a contract between you and your insurance company. While our billing professionals will do all they can to help our patients in communicating and negotiating with their insurance plan or other persons, we must inform patients that if you have any questions regarding coverage, benefits, or payment for services provided, it is the patients responsibility to resolve. In the event of denials, errors, or non-covered services, the patient is responsible for all services rendered. If payment from your insurance carrier is not received within forty-five (45) days, we will seek full payment from you. Balance of services that are delayed or denied by your insurance company due to Coordination of Benefits information will become your responsibility after thirty (30) days. Psymed Solutions and its employees do not guarantee that payment will be authorized for medical services; therefore, this office is not responsible for any adverse payment decisions or misuse of information. Notification of any change in your insurance status (i.e. new company, deductible, co-pay amounts, coinsurance) must be provided to the office forty-eight (48) hours in advance of next visit, or payment in full will be required. Red Flag Policy: (initial) Psymed Solutions must collect and store our patients private medical, financial, and personally identifying data. We must therefore be vigilant in protecting the patient information to which we have access including medical, financial, and any other personal information contained in Psymed Solutions medical, appointment, or billing records. You must present a valid state issued photo identification card prior to being seen at each appointment. If you would like us to bill your insurance carrier, you must present a valid insurance card prior to being seen at each appointment, or payment in full will be required.
Miscellaneous Charges: (initial) Fees for medical records are $25.00 for the first 20 pages, and $.50 for each page thereafter and may take up to 15 business days to obtain. Report preparation fees are based on the time involved. If you do not cancel your appointment 24 hours in advance, our policy is to charge the rate of ($50.00) and is payable prior to future visits. These will not be billed to your insurance company. Please help us to serve you better by keeping your scheduled appointments or canceling in advance. Refill Requests / Messages: (initial) All requests for prescription refills must be made during your office visit. Any phone messages left after 3:00pm Monday through Friday will be returned the next business day. Emergency Situations / After Office Hours: (initial) Medication refills are only addressed during office hours. In an emergency, call 911 or go directly to the nearest emergency room or Carrollton Springs Hospital to be evaluated. Cellular devices, cameras, camcorders or any other recording/ photo taking devices are prohibited: (initial) To reduce the potential risk of a Federal HIPAA Violation recording and/or photo taking devices are prohibited Including but not limited to: cellular devices, camcorders, recorders I have read and understand the Office Policy, and I agree to accept responsibility as described above. I also understand the Office Policy may be amended or modified from time to time by the practice. I am expressing my understanding by initialing next to each item on this page as well as signing below. If you have any questions, please feel free to ask our staff for assistance. Thank you for choosing us for your care. Patient Name (please print) Signature of Patient/Parent/Guardian/Representative Relationship to patient
Pharmacy Information We must have at least one on file: (Please present a prescription card to the front desk if you have one) Local Pharmacy Name: Phone Number: Fax: Address: Local Pharmacy Name: Phone Number: Fax: Address: Name of Mail Order Company: RX ID# Phone# ( ) Prescriptions Currently Taking Name of Medication Dosage Prescribing Physician Any recent Hospitalizations / Outpatient Program: Yes / No If Yes, Where: When: Signature of Patient / Parent / Guardian Signed ***IF THE PATIENT IS A MINOR, PARENT OR GUARDIAN MUST SIGN***
Psymed Solutions ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE ERISA AND OTHER LEGAL AND ADMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE AND/ OR HEALTH BENEFIT PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE Satish Narayan, MD Nisha Satish, MD Humaira Khalid, MD Vivian Kisanga, NP Dominique Wilson, NP ****************************************************************************************** Primary Medicare Supplement/Secondary Carrier Name: Carrier Name: ID#: ID#: Group Name / Number: Group Name / Number: Policy #: Policy #: Ins. Co. Phone #: ( ) Ins. Co. Phone #: ( ) Insured Party Information (If other than Patient): Insured Party Information (If other than Patient): Name: Name: of Birth: / / of Birth: / / Address: Address: SS#: - - SS#: - - Insured s Employer: Insured s Employer: Relationship to patient: Relationship to patient: I hereby assign and convey directly to the above- named health care provide, as my designated authorized representative, all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies and/or medications rendered or provided by the above- named healthcare provider, regardless of its managed care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefits payments. I hereby authorize the above-named healthcare provider to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above-named healthcare provider any and all plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from the above-named health care provider or its attorneys to order to claim such medical benefits. In addition to this assignment of medical benefit and/or insurance reimbursement above, I also assign and/or convey to the above-named healthcare provider any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health insurance, or tortfeasor insurance concerning medical expenses incurred as a result of medical services, treatments, therapies and/or medications I receive from the above-named health care provider (including any right to pursue those legal or administrative claims or chose an action). This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims other legal and/or administrative claims. I intend by this assignment and designation of authorized representative to convey to the above-named provider all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies and/or medications provided by the above-named health care provider, including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims).the assignee and/or designated representative (above-named provider) is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) makes statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings (5) participate in any administrative and judicial actions and pursue claims or chose in action or right against any liable party, insurance company, employee benefit plan, health care benefit plan or plan administrator. The above-named provider as my assignee and my designated authorized representative may bring suit against any such health care benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at provider s expense. Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (health care reform legislation), ERISA, Medicare and applicable federal and state laws. A photocopy of this assignment is considered valid, the same as if it was the original. I HAVE READ AND FULLY UNDERSTAND THE AGREEMENT. Patient signature (Parent /Guardian s signature if patient is under 18) Patient Name (please print) Witness Relationship to patient
Satish Narayan, MD Nisha Satish, MD Humaira Khalid, MD Vivian Kisanga, NP Dominique Wilson, NP *************************************************************************************************************** Advanced Practice Nurse/Nurse Practitioner and Physician Assistant Consent Psymed Solutions would like you to know that we employ Advanced Practice Nurses, also known as Nurse Practitioners, and Physician Assistants to assist us in a team approach to deliver our high quality of medical care. An Advanced Practice Nurse (APN)/Nurse Practitioner (NP) and Physician Assistants (PA) are mid-level practitioners who have received advanced education and training in the provision of health care. Advanced Practice Nurses/Nurse Practitioners or Physician Assistants are not doctors. They can however, diagnose, treat, and monitor routine and complex disorders. If you are seen by an APN/NP or PA, your doctor will review your care with the APN/NP or PA as part of the care plan. I have read the above and understand that in this practice a team approach is used, with my unique needs presented and discussed with one or more physicians in the development of my care plan. I also understand that typically one physician will direct my overall care, but that from time to time I may be seen by any or all the practitioners in this practice, including a APN/NP or PA. I hereby consent to the services of an Advanced Practice Nurse/Nurse Practitioner or Physician Assistant for my healthcare needs. I understand that I can refuse to see the APN/NP or PA and request to see a Physician. I understand that this may require my appointment to be rescheduled. Please sign below to acknowledge that you have read and accept the above. Patient Name (please print) Signature of Patient/Parent/Guardian/Representative Relationship to patient
REVIEW ACKNOWLEDGEMENT OF NOTICE OF PRIVACY POLICIES AND PRACTICES (AVAILABLE IN PRINT UPON REQUEST) I have reviewed Psymed Solutions Notice of Privacy Practices, which explains how my health information will be used and disclosed. I understand that I am entitled to receive a copy of this document. Name of Patient or Personal Representative Signature of Patient or Personal Representative Description Personal Representative s Authority / / Signed
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION MEDICAL RECORDS RELEASE / / - - Patient Name (please print) Social Security Number of Birth A copy of my initial psychiatric evaluation will be sent to my referring physician unless checked Do not send I HEREBY AUTHORIZE DISCLOSURE OF INFORMATION TO/FROM THE NAMED INDIVIDUAL OR ORGANIZATION LISTED BELOW: Release all Health Information Release all Billing (including payments, collections, etc.) Release Other (Specify): Obtain medical records Reason for disclosure: ( ) FULL NAME (Family Member / Doctor / Hospital / Attorney, etc.) Telephone Number Address City State Zip I understand that incomplete forms will be null and void; no exceptions. I understand that disclosure of my health information does not include mailing or faxing copies of my medical records; I must complete the bottom section of this release in order to have copies of my medical records mailed or faxed to the named individual or organization. I understand that specific information to be disclosed may include history of Drug or Alcohol Abuse or Mental Health Treatment, information concerning communicable diseases such as Human Immunodeficiency Virus (HIV), and Immune Deficiency Syndrome (AIDS), laboratory test results, treatment progress, and any other such related information. This authorization will expire 1 year from the date of my signature. I understand that the information released is for the specific purpose stated above. Any other use of this information without the written consent of the patient is prohibited. I understand that a revocation is not effective to the extent that the practice has relied on this authorization in its actions. Also, a revocation is not effective if this authorization was obtained as a condition of obtaining insurance coverage, as other law provides the insurer with the right to contest a claim under the policy or the policy itself. I further authorize that a photocopy of this authorization is acceptable as an original. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal HIPAA privacy regulations. The practice will not condition my treatment, payment, and enrollment in a health plan or eligibility for benefits on whether I provide authorization for the requested use or disclosure. I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification to: Privacy Officer: Attn: Samantha Hogan 7170 Preston Rd., Suite 200 Plano, TX 75024 Phone: 972-232-7474 Fax: 972-232-7401 Name of Patient or Personal Representative Signature of Patient or Personal Representative Witness Description of Personal Representative s Authority PLEASE RELEASE COPIES OF MY MEDICAL RECORDS TO THE ABOVE NAMED INDIVIDUAL OR ORGANIZATION: (By checking one of the following, you will be charged $25.00 for the first 20 pages and.50 for each page thereafter) Entire Record Psychiatric Evaluation (No charge for evaluations sent to referring physicians and/or primary care physicians) Other (Specify): # Pages Copied Request Completed Completed By Denial Sent Charge $ Payment: Cash MC Visa Discover American Express
Policy Subject: Cancellation/No Show Fee Effective: May 1, 2017 Policy Detail: If the patient does not cancel his/her appointment 24 hours in advance, our policy is to charge the rate of $50 and is payable prior to future visits. The no show fee will not be billed to the patient s insurance company. Our confirmation calls are made via an automated system at least two days prior to scheduled appointments. If is the patient s responsibility to ensure Psymed Solutions has most current contact information on file. When a confirmation call is made and the patient does not answer the phone a detailed voicemail will be left. If the patient does not have voicemail set up or the voicemail box is full, patient will still be responsible if he/she does not come to scheduled appointment without canceling. Please remember that the confirmation call is a courtesy service provided by Psymed Solutions. By signing, I acknowledge I have read and understand this policy. Patient Account # Patient Signature Witness Signature
Policy Subject: Patient Tardy Policy Effective: October 7, 2015 Policy Detail: If the patient is more than 15 minutes late to their appointment, they will need to reschedule. We will no longer be working patients into the schedule. If there happens to be an opening in the schedule later that day, the patient may be scheduled in that time slot, otherwise they will have to reschedule. By signing, I acknowledge I have read and understand this policy. Patient Account # Patient Signature Witness Signature
Subject: Notice of No Coverage for Urine Drug Screens Effective: February 3, 2017 Please be aware that your insurance company may not cover your urine drug screen, code G0477 or 80305. Please sign this form indicating that you understand it may not be covered and that you will be responsible for $12 if insurance denies payment. Thank you for your cooperation. By signing, I acknowledge I have read and understand the information regarding my benefits. Patient Account # Patient Signature Witness Signature
Subject: Notice of No Coverage for Injections Effective: September 1, 2016 Please be aware that your insurance company does not cover your injection. Please sign this form indicating that you understand it is not covered and that you will be responsible for $24 each time you have an injection. Thank you for your cooperation. By signing, I acknowledge I have read and understand the information regarding my benefits. Patient Account # Patient Signature Witness Signature
AGREEMENT FOR CONTROLLED SUBSTANCES Patient Name: : of Birth: / / Chart No.: Dear Patient, It is our desire to provide you with excellent patient care and to help you achieve overall health and wellness. To help achieve that goal, your PsyMed Solutions provider may prescribe a Controlled Substance medication (i.e., narcotics, sedatives benzodiazepines, stimulants and/or buprenorphine) which can be very useful, but have a significant potential for misuse and are, therefore; closely controlled by local, state, and federal authorities. In addition, the Texas Medical Board encourages urine drug screens in conjunction with a controlled substance contract to start or continue taking any controlled substance. This is not optional. Failure to sign and abide by this agreement will result in immediate termination of any controlled substances being prescribed by any practitioner in this office. Please carefully read through the entire agreement and initial by each item and fill your name in, indicating that you understand these requirements set forth by all PsyMed Practitioners. We look forward to working with you. Sincerely, Satish Narayan, M.D., Staff, & PsyMed Solutions 1. I am responsible for my medications. If the medications are lost, misplaced, or stolen, REGARDLESS OF THE REASON, I understand that my physician WILL NOT be replacing or refilling my medication. I further understand that early refills WILL NOT be approved. 2. I WILL NOT seek medications from any other physician or practitioner while I m receiving the same medications from my provider of PsyMed Solutions. We will regularly check the Texas Prescription Monitoring Program data base. The data base tells your provider of each prescription for controlled substances that you have filled from all practitioners and pharmacies.
3. Suboxone Patients: I WILL NOT seek opiate medications from any other physician or practitioner while I m receiving Suboxone therapy from my Provider of PsyMed Solutions. I further agree to inform my Provider of PsyMed Solutions of any and all medical or dental procedures that will require the use of opiate medications. I agree to disclose to the surgical or medical physician that I am on Suboxone therapy and will sign a Release of Information for the physicians to consult regarding medications and all surgical or medical procedures. 4. Concerning refills: I agree that refills of controlled substance medications will be made during regular office hours, in person, during a scheduled visit. It is your responsibility to take the medication as prescribed. Early refills will not be made, even if you have run out of your medication early. 5. I WILL TAKE my medications as prescribed and as directed. I will not take extra medication without being advised to do so by my provider at PsyMed Solutions. By doing so ensures that I will not run out of medications early. 6. I WILL NOT use any illicit drugs, as defined by law. These include marijuana, heroin, methamphetamine, cocaine, PCP and hallucinogens or any other mood altering substance that is illegal. 7. I understand that PsyMed Solutions will perform urine drug screening tests, at my expense, to verify compliance of my medication contract. If I am found to be using illegal substances for any reason, my controlled substance medications will be discontinued immediately. NO EXCEPTIONS. In addition, if my urine drug screen is negative for medications prescribed by PsyMed Solutions practitioners, my controlled substances medications will be discontinued immediately and will not be re-prescribed by any physician at PsyMed Solutions. NO EXCEPTIONS. 8. I understand that if I violate any of the above conditions, my controlled substance prescriptions will be immediately terminated and it will be reported to my other healthcare providers, medical facilities and pharmacies.
9. I understand that my provider may discontinue my medication at any time if they no longer think it is clinically appropriate or in my best interest. Additionally, if my controlled substances are discontinued by my PsyMed Solutions provider, this will apply to all other PsyMed Providers as well. No other practitioner in this practice will restart you on the medication. Lastly, once you have violated the agreements in this contract at no time will you ever be prescribed controlled substance by this practice again. 10. I acknowledge the receipt of this agreement and that it has been explained to me in detail by a staff member at PsyMed Solutions. I understand by signing below, I agree to comply with the terms and guidelines of this contract. Patient Printed Name Patient Signature Clinician Printed Name Clinician Signature : / /