NEW PATIENT INFO

Name*

Date of Birth:*

Sex at birth

Gender identity

Street Address*

City:

State

Zip Code*

Home Phone*

Email*

example@example.com

Drug Allergies

Briefly, what is your goal in pursuing psychiatric treatment?

Current Medications (with dosage)

Who is your current Primary Care Provider?

if you have one

Preferred Pharmacy (name and phone or address):

If you currently have health insurance, please take a photo of the FRONT of your insurance card

If you currently have health insurance, please take a photo of the BACK of your insurance card

Do you have any of the following health insurance plans?

What is your policy number?

What is your VA number?

What are the last 4 digits of your SSN?

What is your group number?

What is your Medicare Number?

Do you plan to receive care in person or via online telepsychiatry visits?

In person onlyTelepsychiatry OnlyNot sureBoth

Telepsychiatry Patient Consent Form

In order to receive telepsychiatry services from Flatirons Psychiatry PLLC, you must be a resident of the State of Colorado.

Your telepsychiatry services will be provided by Joshua Raufman, PMHNP, a Colorado-licensed psychiatric nurse practitioner, certified by the ANCC. You can reach Josh Raufman by calling Flatirons Psychiatry at 720-928-0525. Calls are checked during regular working business hours. Telepsychiatry services are not emergency services. IF YOU ARE EXPERIENCING A PSYCHIATRIC EMERGENCY CALL 911 OR GO TO YOUR LOCAL EMERGENCY ROOM. Telepsychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems between a provider and a patient that are not in the same physical location. These services may also include electronic prescribing, appointment scheduling, communication via email or electronic chat, electronic scheduling, and the distribution of patient education materials and forms.

The potential benefits of telepsychiatry are:

- Reduced wait time to receive psychiatric care.

- Avoiding the need to travel to a psychiatric provider.

The potential risks of telepsychiatry include, but are not limited to:

- A telepsychiatry session will not be exactly the same, and may not be as complete as face-to-face service.

- There could be some technical problems (video quality, internet connection) that may affect the telepsychiatry session and affect the decision-making capability of the provider.

- The provider may not be able to provide medical treatment using interactive electronic equipment nor provide for or arrange for emergency care that you may require.

- The provider may not be able to perform certain physical exam parameters, or check vital signs (weight, blood pressure) as in a face-to-face session.

- A lack of access to all the information that might be available in a face-to-face session, but not in a telepsychiatry session, may result in errors in judgment.

- Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment.

- Flatirons Psychiatry utilizes software that meets the recommended standards to protect the privacy and security of the telepsychiatry sessions. However, the service cannot guarantee total protection against hacking or tapping into the telepsychiatry session by outsiders.

Alternatives to the use of telepsychiatry:

- Traditional face-to-face sessions.

Patient responsibilities

- I will not record any telepsychiatry sessions without written consent from my provider. I understand that my provider will not record any of our telepsychiatry sessions without my written consent.

- I will inform my provider if any other person can hear or see any part of our session before the session begins. The provider will inform me if any other person can hear or see any part of our session before the session begins.

- I understand that I, not my provider, am responsible for the configuration of any electronic equipment used on my computer that is used for telepsychiatry. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins. I understand that I must be a resident of the state of Colorado and physically present in the State of Colorado at the time of the encounter to be eligible for telepsychiatry services from Flatirons Psychiatry.

- I understand that my psychiatric provider determines whether or not the condition being diagnosed and/or treated is appropriate for a telepsychiatry encounter.

- I understand that if the telepsychiatry session does not achieve everything that is needed, that I will be given a choice about what to do next. This could include a follow-up face-to-face visit, or a second telepsychiatry visit.

- I can change my mind and stop using telepsychiatry at any time, including in the middle of a video visit. This will not make any difference to my right to ask for and receive health care. I understand that I have the following rights with respect to telepsychiatry:

- I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss of withdrawal of any program benefits to which I would otherwise be entitled.

- The laws that protect the confidentiality of my medical information also apply to telepsychiatry. As such, I understand that the information disclosed by me during the course of my treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.

- I also understand that the dissemination of any personally identifiable images or information from the telepsychiatry interaction to researchers or other entities shall not occur without my written consent.

- I understand that there are risks and consequences from telepsychiatry, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychiatric provider, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

- In addition, I understand that telepsychiatry based services and care may not be as complete as face-toface services. I also understand that if my psychiatric provider believes I would be better served by another form of psychiatric services (e.g. face-to-face services) I will be referred to a psychiatric provider who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychiatry, and that despite my efforts and the efforts of my psychiatric provider, my condition may not improve, and in some cases may even get worse.

- I understand that I may benefit from telepsychiatry, but that results cannot be guaranteed or assured. - I understand that I have a right to access my medical information and copies of medical records in accordance with Colorado law.

Patient consent to the use of telepsychiatry: I hereby consent to engaging in telepsychiatry with Flatirons Psychiatry as part of my psychiatric evaluation and treatment. I understand that “telepsychiatry” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I have read and understand the information provided above regarding telepsychiatry.

Signature

Name of Emergency Contact

Relationship

Home Phone:

Cell Phone

“The practice of both licensed and unlicensed persons in the field of Psychiatry/Psychotherapy is regulated by the Department of Regulatory Agencies. Questions, concerns or complaints may be addressed to: Department of Regulatory Agencies 1560 Broadway, Suite 1340 Denver, Co 80202 (303) 894-7766.

You, as a client, are entitled to receive information about the methods of psychiatry/ therapy, the duration of the therapy (if known) and the fee structure. You may seek a second opinion from another psychiatric provider or may terminate your treatment at any time. In a professional relationship, sexual intimacy is never appropriate and should be reported to the grievance board immediately.”

The information provided by you during any sessions is legally confidential; except for certain legal exceptions which will be identified by the licensee should any such situation arise during therapy.

1. Fees. The fee for an initial visit is $225 for an 80-minute appointment. Subsequent follow up visits are $100 per 30-minute visit or $50 per 15-minute quick visit for medication check-in and refills. Initial Payment is expected at the time of each appointment, unless other arrangements have been made in advance. Checks, cash and some credit cards are accepted. If paying by credit card, patients are required to provide a card to be kept on file and charged on the day of a scheduled appointment.

2. Missed Appointments. The full appointment fee is charged for missed appointments unless they are cancelled 48 hours or more before the scheduled time. Exceptions to this policy will be considered on a case-by-case basis for weather, illness, and circumstances beyond one’s control.

3. Communication. If you need to speak to Josh Raufman, please leave a message at (720)928-0525. Josh will get back to you within 48 hours. For emergencies and/or if you cannot reach Josh Raufman by phone, please call 911. The office address is 954 North Street Suite 204, Boulder CO 80304. Phone: 720-928-0525. Fax: 303-200-7314

4. Prescription Refills. If you require a refill, please call 720-928-0525 or submit a request through the online patient portal. Please do not text Josh for refill requests. Allow a minimum of 48 hours. Please do not rely on a pharmacy fax for refill requests.

5. Insurance. Please contact your insurance company before your appointment so that we can optimize coverage and reimbursement. This practice does not have contracts with any managed care organizations and cannot bill your insurance company. Upon request, we can provide you with a “SuperBill”, which you can send to your insurance company for possible partial reimbursement. You are welcome to submit your invoices to your insurance company, but please be advised that you (or the individual listed as the one to be billed) are responsible for timely payment of your

account balances. Please contact your insurance company prior to your initial visit

6. Termination. Under the care of Josh Raufman, you will need to be seen in the office for a minimum of every six months to continue to be under his care and to have medications be refilled. If you are prescribed any controlled substance medications, you will need to be seen in the office at least every three months. If you have not been seen in 12 months or more, the practice will terminate your case and you will no longer be under the care of Josh Raufman at that time. You may contact the practice to schedule an intake visit to rejoin the practice after that point.

7. Prescription Drug History/Monitoring. Please be aware that, prior to all initial visits, Josh Raufman accesses the Colorado Prescription Drug Monitoring Program to evaluate your controlled substance prescription history. He will also access your prescription drug history through SureScripts, which shows all your prescription drug history through participating pharmacies.

8. Information Needed from You. Please fill out the New Patient Form, HIPAA Form, and Releases of Information, which can be downloaded from the practice website. State and Federal laws require that a Release of Information Form be completed before the Practice can speak with anyone about your care.

9. Josh Raufman’s Credentials. Josh’s CO License number is: RXN.0101294. He is a board-certified Psychiatric Mental Health Nurse Practitioner. He also has a certification as an Adult-Geriatric Health (Internal Medicine) Nurse Practitioner.

I have been informed of my therapist’s degrees, license, address and phone number in writing. I have also read the above information and understand my rights as a patient and agree to and understand the financial arrangement with Josh Raufman, PMHNP-

Please sign here:*

Print name*

Date (mm/dd/year)*

Date

NEW PATIENT INFO

Flatirons Psychiatry

Emergency Contact Information