Established Patient Demographic Update Form

Established Patient Demographics

Please fill out with your most up to date contact information
Patient Name*

First NameMiddle (or Initial) Last Name
Date of Birth*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Mailing Address*

Street Address

Apt or Unit #

CityState

Zip Code
Cell Phone Number*

Area CodePhone Number
Secondary Phone Number:

Area CodePhone Number
Email*
please provide a personal email address (NO school/work emails please)
Preferred Pharmacy:*
Emergency Contact
Name

First NameLast Name
Relationship
Cell phone

Area CodePhone Number
Medical Insurance Details

IF NO INSURANCE OR OUT OF NETWORK PLEASE PUT "SELF PAY" in any required fields. If you have a secondary/supplemental policy to Medicare, please provide this info in the additional information field.
Name of Insurance Company:*
example: Aetna, BCBS of NC, Cigna/Evernorth, Humana, MedCost, United, UMR, Medicare, etc.
Address of Payer:

Street Address

Street Address Line 2

CityState

Zip Code
Member ID #:*
include person number (if any)
Group #:*
Effective Date of Policy:

MonthDayYear
Are you the subscriber/policy holder on this plan?

YesNo
Subscriber's Information

Please provide the policy holder's name, date of birth, sex, social security #, address (if different than the patient's), and relationship to the patient
Subscriber's/ Policy Holder's Name:
Subscriber's Date of Birth:
MM-DD-YYYY
Relationship to Patient:
ex: mother/father, spouse, etc.
Sex:
Social Security Number:
Subscriber's Address IF different than patient's

Street Address

Apt or Unit #

CityState

Zip Code
If someone other than yourself is responsible for payment on the patient's account, then please provide us with a name and address of where bills are to be sent should any balances occur. As per our financial agreement, we do expect payment at the time of service, so please make arrangements with the responsible party to pay PRIOR TO YOUR APPOINTMENT TIME. You may also speak to staff regarding leaving a flex card/health savings card or other payment on file for us to process at each visit.
Please provide any additional information we may need, like secondary insurance information, who and where to send bills to, mail order pharmacy information, a secondary email address, etc...

Please read the following policies and sign below stating that you have read and agree to abide by all office policies for Peace Psychiatry
Cancellation & Missed Appointment Policy

Peace Psychiatry charges for missed appointments or any appointment that is canceled with less than 24 hours’ business day notice. Cancellations must be made 24 hours in advance (not including weekends and holidays). This means if your appointment is on a Monday at 1pm, you must call the Friday before by 1pm in order to cancel without incurring a fee. You must contact the front office staff to cancel (call or leave a voicemail) to reschedule appointments. Please note that we are unable to accept text messages to cancel an appointment.

Appointment reminders (texts/emails) are provided only as a courtesy. We ask that you do not solely rely on reminders, you are ultimately responsible for keeping a record of the day and time of your appointments. Cancellations made less than 24 hours in advance, or no-show appointments, will be charged a missed appointment fee. It is our policy to collect the missed appointment fee prior to rescheduling a new appointment. Your doctor has the right to close your chart and refer you elsewhere if you do not follow up as recommended.
Financial Policy and Insurance Policy

Our practice is committed to providing the best treatment for our patients and we charge the usual and customary rates for our area. Full payment is due at the time of service. We accept cash, check, money order, Visa, MasterCard, Discover, or American Express. Our office does not intervene with family disputes; it is the guardians’ responsibility to provide payment at the time services are rendered. In order to do telehealth appointments, you must provide a payment card to keep on file to be charged for your visits.

Our providers are credentialed and have contracts with several insurance networks. It is your responsibility to check if your doctor is in-network with your mental health carrier. To find out this information, we recommend you call your insurance company prior to your visit. We file with primary insurance only and do not file out-of-network or secondary insurance claims. If we are not contracted with your insurance carrier, you are responsible for full payment at the time of service. If your insurance requires an authorization for your visits, you are responsible to obtain that authorization prior to your appointment.

If you have a deductible, you are responsible for paying for your portion in full at the contracted rate for your insurance carrier until you have met your deductible obligation with that carrier. If your insurance carrier requires a co-payment or a co-insurance, this is to be paid at each visit.

It is your responsibility to notify the office if you have a change in insurance coverage and provide us with an up to date insurance card at each visit. We collect the patient responsibility (portion/copay) at the time services are rendered. For this reason, we recommend you call your insurance and find out your mental health office visit benefits prior to your appointment, thenceforth you will be prepared to pay your portion.

You are responsible for payment of services rendered regardless of any determination made by an insurance company. Insurance will not pay for missed appointments. Unless canceled at least 24 hours (business day) in advance, it is our policy to charge the office visit rate for the missed appointment. Please let us know if you have any questions or concerns regarding our financial policy.
APPOINTMENTS: Services are by appointment only. This time slot has been reserved just for you. In the event of an emergency, every effort will be made to work you into the schedule. It is recommended that you plan to arrive early and anticipate possible delays such as traffic. In theevent that you run late, you will not be given additional time as this may interfere with another patient’s reserved time. If an appointment is missed, you will be billed according to our missed appointment policy.

MESSAGES: All messages will be returned as promptly as possible. No messages will be checked on weekends or standard holidays. If you need urgent assistance, you may call the on call provider. This will not be charged if the phone call is truly needed, but you may incur a cost for phone conversations over 10 minutes in length. In the event of an emergency, call 911 or go to the nearest emergency department for treatment.

REFILLS: Refills will typically be handled during your office visit. Refills may not be given if you have not been seen in the last 3-6 months. Please allow 72 hours for prescription refill requests to be processed and please note that we close early on Fridays. Request non-controlled medication refills through your pharmacy at least 2 days prior to running out of medication. For refills on controlled substances, you must send this request through the patient portal, or by leaving a message on your provider's voicemail, 3-5 days prior to running out of medication. A nominal fee may be charged for same day/after hours prescription refills. If your medication requires a Prior Authorization (PA), please allow additional time for your prescription to be approved by your insurance. Make sure our office and your pharmacy has up to date insurance information in order to get PA approval. Have the pharmacy fax us the PA notice as soon as possible.

FEES: Fee structures are subject to change based on the severity of presenting concerns, appointment length, and services provided. The providers at Peace Psychiatry have your best interest in mind and alter
their scheduling to accommodate meeting your needs. Fees may be added to your account for both direct and indirect patient care for the following purposes as listed below. We value you as a patient of the practice and should you have any questions or concerns, please feel free to discuss any pricing or financial issues with the practice manager or owners.

1. Paperwork/Forms - Peace Psychiatry providers will make every attempt to complete forms during your office visit if time allows for this, but may not always guarantee this can be completed. Please notify the office staff if you require a longer appt time for filling out paperwork, and please have paperwork ready to go at the time of your appt. In the event these forms require more time and resources, additional fees may occur; however, you will be notified prior to being charged.

2. After Hours - A provider is available to you after closing hours for urgent matters only. Please note that any issues that require longer than a 10 minute phone call will be charged at a rate of $20 per ten minute intervals. We ask that you be mindful on your purpose for calling as this line is not for appointment scheduling or refill requests.

3. Missed Appointments - We charge a missed appointment fee (DNKA) for no shows or for canceling less than 24 hours in advance (not including weekends and holidays). The New Patient (60 minutes) DNKA fee is $300, therapy sessions (40 minutes) DNKA fee is $150, and for a follow up medication management (20 minutes) the DNKA fee is $125.

TERMINATION: At times, termination between a patient and provider is necessary. Termination of treatment may occur at any time and may be initiated by either the patient or the provider. Reasons for termination by the provider are generally due to non-compliance with treatment, missed appointments, or violation of office policies. If you have any questions about this, please discuss with your provider. In the event that your care needs to be transferred to another psychiatric provider, Peace Psychiatry will provide assistance as able.

PRESCRIPTION MEDICATIONS: As a patient, you are responsible for the following regarding prescription drugs/medications:
1. I am responsible for my medications. I will NOT share, sell, or trade my medicine.
2. I will not take anyone else’s medicine.
3. I will not increase, decrease, or stop my medicine until I speak with my provider.
4. My medicine may not be replaced if it is lost, stolen, or used up sooner than prescribed.
5. I will keep all appointments set up by my doctor (e.g., primary care, physical therapy, mental health, substance abuse treatment, pain management, hospitalizations, etc.)
6. I will bring the pill bottles with any remaining pills of a medication if requested by my provider.
7. I agree to give a blood, saliva, or urine sample, if asked, to test for drug use and medication compliance.
8. If I break any of the rules, or if my provider decides that this medicine is hurting me more than helping me, this medicine may be stopped by my provider in a safe way.

If I have questions, I will talk to my provider about this agreement and I understand the above rules.
By signing below, you have read and agree to all of the above policies and the following statements:

The information I have provided to the office is true, to the best of my knowledge. I authorize Peace Psychiatry, PLLC to release any information required to process my claims and to have my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance or denial of claims. I understand that Peace Psychiatry has the right to refuse services if I violate any of the office policies.
Signature*

Clear
Should be Empty:

Established Patient Demographics

Emergency Contact

Medical Insurance Details