NEW PATIENT FORMS - BAKERSFIELD

NEW PATIENT INTAKE FORM

Precision Psychiatric Services
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CONTACT INFORMATION
Name

First NameLast Name
Birth Date (DOB)

MonthDayYear
Social Security:
Sex
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (home)

Area CodePhone Number
Phone Number (cell)

Area CodePhone Number
Email (optional)
example@example.com
Referred by:

INSURANCE INFORMATION
Primary Insurance
Policy/ID Number
Group Number
Secondary Insurance (include any Medi-Cal plans)
Policy/ID Number
Group Number
AS A PATIENT, OR AS A LEGAL GUARDIAN OF MINOR PATIENT, I AGREE TO PAY FOR ALL SERVICES RENDERED. THIS OFFICE MAY BILL MY ISURANCE CARRIER AS NEEDED. I AM FINANCIALLY RESPONSIBLE FOR ALL NON-COVERED SERVICES. I AUTHORIZE THIS OFFICE TO RELEASE MY INFORMATION TO PROCESS ANY REQUESTS.
Signature
Date

AUTHORIZATION FORM
FOR PATIENTS UNDER 18 YEARS OF AGE: I certify that I have legal guardianship of the patient and I am authorized to make healthcare decisions for the patient. Please initial below.
I HEREBY AUTHORIZE PRECISION PSYCHIATRIC SERVICES, INC TO RELEASE ALL MEDICAL INFORMATION TO THE ABOVE NAMED INSURANCE CARRIER OR TO A DESIGNATED ATTORNEY FOR THE PURPOSE OF CLAIMS ADMINISTRATION AND EVALUATION UTILIZATION REVIEW AND FINANCIAL AUDIT. THIS AUTHORIZATION REMAINS VALID AND EFFECTIVE FROM THE DATE OF SIGNING UNTIL REVOKED IN WRITING.

I UNDERSTAND THAT I MAY REQUEST A COPY OF THE AUTHORIZATION.

I READ THIS AUTHORIZATION AND UNDERSTAND IT.

I HEREBY ASSIGN TO PRECISION PSYCHIATRIC SERVICES ALL MONEY TO WHICH I AM ENTITLED TO FOR MEDICAL AND/OR SURGICAL EXPENSES RELATIVE TO THE SERVICES RENDERED BY PRECISION PSYCHIATRIC SERVICES BUT NOT TO EXTEND MY INDEBTEDNESS TO SAID PHYSICIAN AND/OR SURGEON.

IT IS UNDERSTOOD THAT ANY MONEY RECEIVED FROM THE ABOVE NAMED INSURANCE COMPANY OVER AND ABOVE MY INDEBTEDNESS WILL BE ASSESSED TO MY ACCOUNT.

I UNDERSTAND I AM FINANCIALLY RESPONSIBLE TO PRECISION PSYCHIATRIC SERVICES FOR CHARGES NOT COVERED BY THIS AGREEMENT.

I FURTHER AGREE IN THE EVENT OF NON PAYMENT TO BEAR THE COST OF COLLECTIONS AND/OR COURT COST AND REASONABLE LEGAL FEES SHOULD THIS BE REQUIRED.
Signature
Date
TREATMENT CONSENT

Please initial the following statements in the spaces provided:
I authorize and request that Precision Psychiatric Services provides treatment which is advisable in the course of my care as a patient. The frequency and type of treatment will be decided between my provider and me.
I understand that if any medication is prescribed during the course of my treatment that any risk and side effects will be explained to me at the time and that I may request to stop medication at any time. I agree to discuss the decision to discontinue medication and the possible side effects that may occur from this decision with my provider before acting upon this decision.
I understand that maximum benefit will occur with consistent attendance and compliance with treatment (medications, counseling, etc.) as suggested by my provider, but no guarantee of the results of treatment may be expected.
Please be advised that we DO NOT provide evaluations (diagnoses) or treatment for litigation purposes. Litigation purposes would include criminal cases, divorce, personal injury and emotional distress types of cases, among others. If you are seeking evaluation and treatment for a litigation purpose, we recommend that you retain a physician and/or psychologist who perform such legal evaluations and treatment. The providers of Precision Psychiatric Services DO NOT provide litigation evaluations or treatments; our purpose is strictly to assist YOU.
I have read and fully understand this Treatment Consent form. Signature
Date

PRACTICE GUIDELINES

The following is a list of guidelines that will allow for efficient use of your time and that of the practice's time. Please authorize the specific practices by initialing in the spaces provided and signing below.
I give permission to Precision Psychiatric Services to remind me by telephone of my appointments. This permission extends to allowing Precision Psychiatric Services to leave a reminder of my appointment on my message machine or voicemail.
I give permission for the provider to use my first name in the waiting room when calling me back from my session.
I give permission to fax any essential information to my primary physician, pharmacy, HMO, insurance provider, hospital, and/or other medical provider involved in my treatment (i.e. faxing a refill authorization to your pharmacy).
I understand that if I am more than 10 MINUTES LATE to an appointment, the appointment will be rescheduled and a NO SHOW FEE of $60.00 will be charged to my account, at the provider's discretion.
I understand that if the patient is a minor (under 18 years of age), a parent, guardian, or authorized person must accompany them to the appointment.
Signature
Date

MISSED APPOINTMENT POLICY

INITIALS and SIGNATURE signifies an understanding and agreement to the following:
It is my responsibility to notify Precision Psychiatric Services 24 hours prior to the scheduled appointment if I intend to cancel or reschedule that appointment. WE DO NOT ACCEPT CANCELLATIONS THROUGH OUR ANSWERING SERVICE.
I will be billed for all missed appointments, late cancellations, and late rescheduled appointments at the standard office rate of $60.00.
I agree to pay this amount in the event that I miss an appointment or fail to cancel or reschedule 24 hours prior to scheduled appointment.
Payment of these above mentioned fees is required before another appointment can be made.
Signature
Date

MEDICATION COMPLIANCE CONTRACT

I, the undersigned, agree to be in compliance with all medication management appointments and treatment plans with Precision Psychiatric Services. I understand that my physician is requiring me to return as medically needed for these appointments (as per his or her discretion).
Name

First NameLast Name
Birth Date

MonthDayYear
Signature
Date

CONTROLLED PRESCRIPTION POLICY
Due to widespread abuse of controlled substances in our community, as well as increased DEA censorship of doctors’ lack of monitoring of controlled substances, Precision Psychiatric Services is implementing a strict controlled substance policy for all patients, effective immediately.

1. Controlled prescriptions include stimulants (ADHD meds such as Ritalin, Adderall, Concerta, Vyvanse) and benzo/hypnotics (Ativan, Xanax, Klonopin, Ambien, Lunesta).

2. Precision Psychiatric Services (PPS) will not refill controlled substances over the phone. It is your responsibility to ensure you have an appointment to see a PPS psychiatrist or nurse practitioner before you run out of the controlled substance.

3. PPS will not prescribe any controlled substances to you if you have not been seen in 90 days, for proper monitoring and safety.

4. PPS will not refill any controlled substances prescribed by another clinician even if you and that clinician have your own personal agreements.

5. If a controlled substance is sent to a pharmacy, PPS will not send duplicate copies of the same medication to another pharmacy. Please inform the PPS psychiatrist at the time of the appointment if you would like the medication sent to a new pharmacy. Once the controlled substance is sent, PPS is unable to send the same prescription for a minimum of 30 days.

6. If you have found yourself over using or abusing controlled substances, or if you run out and experience withdrawal symptoms, please call the office and we will assist you the best way possible.
I verify that I have received this information and consent to the guidelines, as set forth by my physician.
Please type your first and last name.
Signature
Date

Please attach a photo of the front side of your photo ID (driver's license).

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Please attach a photo of the back side of your photo ID (driver's license).

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Please attach a photo of the front side of your health insurance card.

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Please attach a photo of the back side of your health insurance card.

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Submit Completed Form
I certify that the information submitted in this application is true and correct to the best of my knowledge.
Signature:
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NEW PATIENT INTAKE FORM

SELECT A LOCATION:

CONTACT INFORMATION

INSURANCE INFORMATION

AUTHORIZATION FORM

TREATMENT CONSENT

PRACTICE GUIDELINES

MISSED APPOINTMENT POLICY

MEDICATION COMPLIANCE CONTRACT

CONTROLLED PRESCRIPTION POLICY

Submit Completed Form