Minor New Patient Paperwork

Patient Data - Minor
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number

Area Code Phone Number
Biological Sex *
Parent/Guardian 1 Name *

First Name Last Name
Parent/Guardian 1 Phone Number *

Area Code Phone Number
Parent/Guardian 1 Email *
example@example.com
Parent/Guardian 2 Name

First Name Last Name
Parent/Guardian 2 Phone Number

Area Code Phone Number
Parent/Guardian 2 Email
example@example.com
Patient Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Appointment Reminder? *

Financial Responsibility

for {patientName} DOB: {dateOf}
Responsible Person's Name *

First Name Last Name
Responsible Person's Date of Birth *

Month Day Year
Date
Responsible Person's Phone Number *

Area Code Phone Number
Responsible Person's Email *
example@example.com
Responsible Person's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
The office will keep a current credit card on file. I allow the office to charge fees not coverable by the insurance such as for non-coverage, yearly admin charge, unmet deductibles, unpaid copays, and no-show charges. A statement of such charges will be sent to you.

I agree to pay all bills as presented and all reasonable fees associated at the time with the collection of such charges including fees for bounced checks, rush Rx, yearly admin charges, copays, phone consultation charges not covered by insurance, same day cancellation and no-show fees, request for copy of records, school form filling etc. per schedule of fees attached currently in force.
Responsible Persons Signature for Financial Responsibility Form *

Clear
Date of Signature on Financial Responsibility Form *

Month Day Year
Date

Schedule of Fees

for {patientName} DOB: {dateOf}

{patientName}

Fee	Charge	Notes
New Eval. appointments	$460	Approx 40-60 minutes (billed to insurance if Dr. is in-network)
Annual Admin Charge	$50	Admin Fee is payable at the first visit of the year - not covered by insurance. This is in addition to your copay.
Standard Follow Up	$190	Approx 15-25 minutes (billed to insurance)
Complex Follow Up	$320	Approx 30-40 minutes (billed to insurance)
No show or Late Cancellations	$75-190	All changes or cancellations less than 48-hour notice
Rush Refill Requests	$10	48 Hours or Less to fill RX
Letter/Forms	$25/per item	NO CHARGE IF ADMIN FEE PAID Personal letters/forms for schools, lawyers, psychologists, airlines, others

Patient: {patientName} Date of Birth: {dateOf}
Parent/Guardian Signature for Schedule of Fees *

Clear
Date of Signature for Schedule of Fees *

Month Day Year
Date

Consent to Release & Echange Information

for {patientName} DOB: {dateOf}

If you have seen other professionals regarding this problem and would like us to co-ordinate with them, please provide us this consent. For young patients, his or her pediatrician must be added.

I am requesting you to provide all pertinent medical information about the patient listed above to doctors of East Bay Psychopharmacology Group. This information may be in electronic from such as a PDF file sent via email (ebpgoffice@comcast.net) or by hard copy mailed to above address.

I am giving my consent to both parties to share and exchange information as appropriate for the care of the patient.
Professional's Name/ Medical Office Name / Other's Name
Please fill the persons name, medical office or other (family member, friend, etc.) you would like the doctor to communicate with.
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Professional's Name/ Medical Office Name / Other's Name
Please fill the persons name, medical office or other (family member, friend, etc.) you would like the doctor to communicate with.
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian's Signature for Consent to Release Info Form

Clear
Date of Parent/Guardian Signature for Consent Form

Month Day Year
Date

Office Policies and HIPAA Policy Acknowledgement

for {patientName} DOB: {dateOf}
- Our HIPAA policy is posted on our website: www.EastBayPharm.com. Please be sure to read it.
- The office staff is available to answer your call from 10 AM to 4 PM. Monday to Thursdays and we are available by email.
- A $50 admin fee is charged yearly for all accounts. This fee is not billable to insurance and needs to be paid annually.
- We charge $190 for all changes and cancellation of appointments with less than 2 business-day notice. There are no exceptions for this (including sickness, work travel, etc.) This is a typical policy for psychiatric office where a considerable time is set aside with no double booking.
- We use an electronic reminder service for your upcoming appointment. The reminders will come via email and phone.
- You may email us about yourself or the patient if you wish. Please clearly indicate the patient name and the doctor to whom your communication is directed. The doctors review the emails daily in most cases. If it is urgent, please call the office instead of emailing. Standard emails are not hack-proof but are considered HIPAA compliant.
- Refills are done using electronics means. This is secure and avoids errors. Please do not call the office for refills.
- Most Rx refills require regular follow-up as suggested by the doctor. Rx refill requests must be made in writing via website or email.
- For medication refills (Schedule II medications) we require a 7 day notice. Other medications require a 3 day notice. Urgent refill requests, with less than 3-day notice will be charged a $10 rush fee.
Parent/Guardian Signature for Office Policies & HIPAA *

Clear
Date of Signature for Office Policies & HIPAA *

Month Day Year
Date

If you will be using your medical insurance to pay for visits to this office….
- Insurance coverage is for a particular doctor - not the office.
- If your insurance changes, let us know immediately. Transactions older than 90 days cannot be billed to insurance.
- If you have any other insurance plan, please send the superbill given to you by the office to your company. They will reimburse you directly based on your deductible and out of network coverage.
- We require a credit card on file for timely payment of amount due to this office for all unpaid charges.
- We do not verify your coverage. This is your responsibility. If you are seen by the doctors and your insurance deems the charges not covered, you are responsible for them.
- Please check with your insurance as to what your deductible is. During the first quarter of the year, you are expected to pay the contracted rate at the time of service. We require full payment of agreed upon rate at time of visit if you have not met your deductible.
- Phone consultations over 10 minutes are charged. Your insurance most likely will not cover these.
- Some services such as phone consultations with other providers, review of records, no-show charges, cancellation fees, form filling, reports etc. are often NOT a reimbursable expense. If these services are used or requested by you, you are responsible for their charge.
- If after billing your insurance company we find that you do not have coverage, have not met the deductible, or for any other reason, the amount due will be charged to your credit card on file after 30 days.
- Please call your insurance and make certain that you are covered for seeing this office, the doctor with whom you have the appointment and understand clearly your deductibles and your coverage. For purposes of meeting your deductible, please be advised that typical charges from this office may be app. $1500 per year.
Patient: {patientName} Date of Birth: {dateOf}
Parent/Guardian Signature for Insurance Acknowledgment *

Clear
Date of Signature on Insurance Acknowledgment *

Month Day Year
Date

As a non-medicare provider, we are obligated to ask you to sign this agreement.

If the patient is a Medicare Part B beneficiary seeking services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of 1997. The Physician has informed Patient that Physician has opted out of the Medicare program effective on Jan 1, 2013 for a period of at least two years, and is not excluded from participating in Medicare Part B under Sections 1128, 1156, or 1892 or any other section of the Social Security Act.

Physician agrees to provide the following medical services to Patient (the "Services"): Psychiatric evaluation and management
In exchange for the Services, the Patient agrees to make payments to Physician pursuant to the Attached Fee Schedule. Patient also agrees, understands and expressly acknowledges the following:
Patient agrees not to submit a claim (or to request that Physician submit a claim) to the Medicare program with respect to the Services, even if covered by Medicare Part B.
- Patient is not currently in an emergency or urgent health care situation.
  Patient acknowledges that neither Medicare's fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services.
- Patient acknowledges that Medi-Gap plans will not provide payment or reimbursement for the Services because payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny reimbursement.
- Patient acknowledges that he has a right, as a Medicare beneficiary, to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare, and that the patient is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out.
- Patient agrees to be responsible, whether through insurance or otherwise, to make payment in full for the Services, and acknowledges that Physician will not submit a Medicare claim for the Services and that no Medicare reimbursement will be provided.
- Patient understands that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were submitted.
- Patient acknowledges that a copy of this contract has been made available to him.
- Patient agrees to reimburse Physician for any costs and reasonable attorneys' fees that result from violation of this Agreement by Patient or his beneficiaries.
Patient: {patientName} Date of Birth: {dateOf}
Parent/Guardian Signature for Medicare Opt Out *

Clear
Date of Signature for Medicare Opt Out *

Month Day Year
Date

Contract for Controlled Substances

for {patientName} DOB: {dateOf}

Controlled substance medications (i.e., benzodiazepines and stimulants) are very useful. However, they have potential for misuse and therefore are controlled by local, state, and federal authorities. Because my provider is prescribing such medications for me, I agree to the following conditions:

1. I am responsible for the controlled substance medications prescribed to me. If my prescriptions and/or medication are misplaced, stolen, or if “I run out early”, I understand that this medication will not be replaced regardless of the circumstances.

2. I will not request or accept controlled substance medication from any other physician or individual while I am receiving such medication from EBPG. Besides being illegal to do so, it may endanger my health. I understand that if I violate any of the above conditions, my prescriptions for controlled medications may be terminated immediately. If the violation involves the concomitant use of non-prescription or illicit (illegal) drugs, I may also be reported to other physicians, pharmacies, medical facilities, and the appropriate authorities.

3. I am aware that all requests for prescriptions must be in writing during business hours. I am responsible for taking the medication in the dose prescribed and for keeping track of the amount remaining. Renewals are based upon keeping scheduled appointments. Refills will not be made as an “emergency”. No controlled medications can be ordered when the office is closed. I understand the importance of following my treatment plan as directed by my physician and agree to keep my scheduled appointments.

4. I understand that if I violate this controlled substance contract due to non-compliance of medical directions, such as: failure in taking medications as prescribed, utilizing other illicit drugs, obtaining similar medications from others, or abuse of controlled medications, I may be subject to dismissal from this practice.

5. I understand that the main treatment goal is to improve my ability to function. I am being given potent medication to help me reach that goal and agree to help myself by following better health habits. I understand that using illicit drugs will negatively impact my progress. Continued use of illegal or illicit substances after warning can be cause for termination of medical care and reporting to authorities.

I have read this contract and fully understand its content and the consequences of violating this contract. By signing below, I accept the above treatment agreement.
Parent/Guardian Signature for Controlled Substance Contract *

Clear
Date of Signature for Controlled Substance Contract *

Month Day Year
Date

Medical History

for {patientName} DOB: {dateOf}
Please list your questions and concerns:
Has the patient seen other specialists for these problems/symptoms? If so, please provide approximate dates.
Who were you referred by?
Who is the Minors Primary Care Physician (PCP)?
PCP's phone number

Area Code Phone Number
Other Physicians/Therapists currently involved in patients care (please provide Name, specialty, phone number, and city)
Neonatal History: Please list significant issues related to pregnancy, birth, and immediate post-partum period, including prematurity, forceps delivery, meconium, birth trauma, jaundice, colic, etc.
Medical: Please list any significant illnesses, surgeries, and hospitalizations. Please include head injuries, seizures, vision or hearing loss, etc.
Medications: Please list all PAST medications, including vitamins and supplements: Please provide Name, daily dosage, approximate dates, and reason stopped.
Medications: Please list all CURRENT medications, including vitamins and supplements: Please provide Name, daily dosage, and who prescribed the medication.
Have you had an allergic reaction to any medication? If yes, please state medication and extent of reaction. *
Do you have a history of medical and psychiatric hospitalizations? Please provide year and reason of hospitalization.

School History

for {patientName} DOB: {dateOf}
Name of School Patient Attends
Grade
School History: Please specify any behavioral and academic problems, repeated grade, etc. (Include patient age, grade and school during these problems.)

	Mother	Father	Sibling	Grandparent	Aunt/Uncle
Bipolar Disorder/Depression
Schizophrenia
OCD
Learning Disability
ADHD
Psychiatric Hospitalization
Suicide/Suicide Attempts

	Never (None)	Sometimes (Mild)	Often/Always (Severe)
Easily distracted from task
Difficulties focusing, can't start task
Poor attention to details, careless mistakes
Forgetful, losing things
Poor Planning, procrastination
Daydreaming
Shifts from one activity to another
Can't wait for his/her turn
Leaves work unfinished
Acting before thinking, interrupts
Fidgets and squirms
Talking excessively, can't stop
Moving constantly, can't sit still
Liking sameness, routine, no changes
Extremely stubborn
Transitions are difficult
Perfectionist, works slow
Very sensitive (to loud noise, tags, smells)

	Never (None)	Sometimes (Mild)	Often/Always (Severe)
Argues with parent, adults
Refuses rules
Loses temper, gets angry, screams
Feelings are easily hurt, gets frustrated
Gives up easily
Deliberately vandalized property
Lies, "cons" to get what (s)he wants
Bullies, intimidates others
Have stolen from a store, others
Got into fights, used a weapon
Physically cruel to people & animals
Callous, feels no guilt
Smokes, drinks, drugs
Truant from school
Has been arrested, committed illegal act

	Never (None)	Sometimes (Mild)	Often/Always (Severe)
Eye blinking
Facial movements
Head or body jerking
Nervous coughs, grunts, snorts
Bites nails, cracks knuckles, picks skin
Chews on cloths
Can't get mind of certain things
Fears that might do something bad
Concerned about order and neatness
Stores things, can't discard them
Repeats certain acts over and over

	Never (None)	Sometimes (Mild)	Often/Always (Severe)
Worrying excessively about everything
Tense, needs lots of reassurances
Very shy and timid, clingy
Extremely self-conscious (worries what others are thinking/saying about him/her)
Easily embarrassed, sensitive to criticism
Panic attacks now or in the past
Excessive Fear of dark, heights, bees, etc.
Had separation problems as a child
Nervous stomach, headaches
Family history of anxiety, panic, or social phobia
Excessive tiredness, daytime sleepiness

	Never (None)	Sometimes (Mild)	Often/Always (Severe)
Irritable, touchy, grouchy, easily angry
Unhappy most of the day, most days
Cries easily, has sad thoughts
Talks about dying, sad themes in play
Talks about wanting to die
Feels things will never get better
Does not enjoy anything anymore
Major changes in sleep and appetite
Feels worthless, inferior (eg I'm stupid)
Feels guilty, too hard on self
Feels that be better off dead
Harmed self (cutting, scratching, burning)
Mood changes, quickly, drastically
Episodes of being talkative, pressure to talk
Periods of extreme energy alternating with periods of excessive tiredness and quiet
Brags, shows off, reckless
Goes through uncontrollable rages
Early preoccupation with sex
Family history of depression or bipolar disorder

	Never (None)	Sometimes (Mild)	Often/Always (Severe)
Talks to self, hears what others can't hear
Feels others are out to get him/her
Strange, bizarre, odd behavior, talk
Believes in reading minds
Has strange, bizarre tasks

	Never (None)	Sometimes (Mild)	Often/Always (Severe)
Bedwetting
Soils underwear
Sleeps too much, always tired
Hard time falling asleep
Sleepwalking, -talking, night terrors

	Never (None)	Sometimes (Mild)	Often/Always (Severe)
Socially awkward, misses social cues
Does not look in the eyes
Prefers playing alone, refuses group activities
Bullies, provokes fights, teases others

	Never (None)	Sometimes (Mild)	Often/Always (Severe)
School work is hard, confusing
Behind in reading, math
Had to repeat a grade or was held back
Homework takes all night to finish