Please complete all information on this form prior to your first visit. It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history. Thank you!

Current Concerns

Please check all of the symptoms below that apply to you.

Suicide Risk Assessment

Past Psychiatric Medications

Please check all past medications.

Past Psychiatric Treatment

Trauma History

Medical Information and History

For Women

Medical Issues

Family Medical History

Family Psychiatric History

Educational History

Occupational History

Relationship History and Current Family

Spiritual Life

Legal History

Exercise Level

Substance Use

Tobacco History

Family Background and Childhood History

Copyright © 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MDC is a trademark of Pfizer Inc.

A2663B 10-04-2005

Patient Restrictions on Methods for Disclosure

I have chosen to receive mental health services in the form of Psychiatric/Therapy sessions for myself from Michigan Psychiatric Primary Care Clinic. My decision is voluntary, and I understand that I may terminate these services at any time, unless my participation has been mandated by a court of law.

Nature of Mental Health Services

I understand that during my treatment I may need to discuss material of any upsetting or uncomfortable nature in order to resolve my problems. I also understand it cannot be guaranteed that I will feel better after completion of treatment.

Compliance with treatment plan

I agree to participate in the development of an individualized treatment plan. I understand that consistent attendance is essential to the success of my treatment. Frequent "no shows" and/or late cancellations (less than 24hr notice), which there is a $50 fee for every time, may be grounds for termination of services, as well as failure to follow my treatment plan in any form.

Client Rights

• The right to be treated with dignity and respect by all staff
• The right to be involved in the planning and/or revision of my treatment plan
• The right to know about my treatment progress or lack thereof
• The right to reject the use of any therapeutic technique, and to ask questions at any time about the methods used
• The right to be spoken to in a language that is fully understood
• The right to a clean and safe environment
• The right to refuse to be video taped, audio recorded, or photographed
• The right to end treatment at any time unless court ordered
• The right to file a complaint or grievance about the agency or staff
• The right to confidentiality of clinical records and personal information according to federal and state law

Emergencies

I understand I may reach Michigan Psychiatric and Primary Care Clinic at 517-332-5342. If not available, I can leave a message and my call will be returned as soon as possible. If I have a life-threatening emergency, I am to call 911 or go to my nearest Emergency Room.

BY SIGNING THIS, I AGREE I HAVE RECEIVED THIS PRACTICE'S NOTICE OF PRIVACY PRACTICES written in plain language. The Notice provides in detail the uses and disclosures of protected health information that may be made by this practice, individual rights and the practices' legal duties with respect to protect health information. The Notice includes:

• A statement that this practice is required by law to maintain the privacy of protected health information.
• A statement that this practice is required to abide by the terms of the notice currently in effect.
• Types of uses and disclosures that this practice is permitted to make for each of the following purposes: treatment, payment, and health care operations.
• A description of each of the other purposes for which this practice is permitted or required to use or disclosure protected health information without my written consent or authorization.
• A description of uses and disclosures that are prohibited or materially limited by law.
• A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization.
• Individual rights with respect to protected health information and a brief description of how I may exercise these rights in relation to:
  • The right to complain to this practice and to the Secretary of HHS if I believe privacy rights have been violated, and that no retaliatory actions will be used against me in the event of such a complaint.
  • The right to request restrictions on certain uses and disclosures of protect health information, and that this practice is not required to agree to a requested restriction.
  • The right to receive confidential communications of protected health information.
  • The right to inspect and copy protected health information with reasonable charges.
  • The right to amend protected health information by adding notes.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request.

This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice's current Notice of Privacy Practices on request.

BY SIGNING THIS POLICY YOU AGREE YOU UNDERSTAND AND AGREE TO BE BOUND BY THE FOLLOWING TERMS:

1. Payment is due at the time of service unless arrangements have been made in advance by your insurance carrier. We accept most debit, Discover, MasterCard and Visa credit cards.
2. You agree to disclose to Michigan Psychiatric & Primary Care Clinic all insurance coverage in effect at the time of service. We will also need to know policy numbers, group numbers, the policyholder information and the guarantor information. You understand you need to provide copies of all current insurance cards or other identifying insurance information, failure to do so may result in additional charges to you to cover costs incurred by us.
3. That your insurance policy is a contract between you and your insurance company. We cannot interfere with that contract. As a service to you, we will file your insurance claim and you assign the benefits to the doctor—in other words, you agree to have your insurance company pay the doctor directly.
4. We have made prior arrangements with many insurance companies and health plans to accept an assignment of benefits. If we have a contract with your insurance company, we will bill them for you, and you may be required to pay a copayment at the time of your visit or after the insurance company or health plan adjudicates your claim.
5. If a plan or insurance company with whom we do not have a prior arrangement insures you, we will prepare and send the claim for you on an unassigned basis. This means the insurer may send the payment directly to you. If this is the case, our charges for your care are due at the time of service.
6. If we contract with an insurance company or plan, we must follow their master charge list and charge you the amounts they determine should be charged for services rendered. We cannot guarantee your insurance will provide you with "in-network" benefits or any specific charges or payments. We will not "discount," "adjust" or "write off' amounts your insurance company determines are "allowed," "member liability" or should be paid by you.
7. Not all insurance companies or plans cover all services. In the event your insurance plan determines a service to be "not covered," you may be responsible for the entire charge. If you have an insurance plan with which we do not have a contract, you may be balance billed for any charges not covered by your plan. Payment is due upon receipt of an invoice from our office.
8. If your insurance company or health plan does not pay the practice within a reasonable period, or in full, we will expect you to pay any outstanding charges. If we later receive a check from your insurer, we will refund any overpayment to you.
9. If you or your child has Medicaid, you can waive their right to have Medicaid pay for services. THIS WAIVER IS NOT REVOCABLE, ONCE CHOSEN, NO SERVICES WILL BE BILLED TO MEDICAID; YOU WILL BE RESPONSIBLE FOR THE PAYMENT OF ALL SERVICES. If you chose to do this initial below:

10. If a check is returned or not honored by your bank, you will be required to pay a $35.00 fee.
11. If we have to invoice you for an outstanding amount beyond the first invoice, you will be required to pay a $1.00 fee per page for each additional page thereafter.
12. If the amount owed Michigan Psychiatric & Primary Care Clinic is not paid within 90 days of invoicing, the account will be sent to a collection agency. You will then be required to pay an additional fee equal to 50% of the original amount owed, in order to cover our costs and inconvenience involved with obtaining payment.
13. Failure to cancel or reschedule a scheduled appointment at least 48 hours before your scheduled appointment will result in a $50 fine. Patient or patient guardian will be required to pay the $50 fee before or at the time of your next scheduled visit.

I have read and understand the practice's financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time without direct notice to me and agree to be bound by any amendments.