Dr. George D. Cox
PO Box 6588
Maryville, TN
37802-6588
Email:
doug@drgdcox
Phone:865-386-6392
Name
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First Name
Last Name
Patient ID
Will be added later
Date
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Month
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Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Email
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example@example.com
SS Number
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Marital Status
Married
Single
Divorced/Separated
Widowed
Employer
Job/Occupation
Work Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Physician
Primary Care Physician Phone Number
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Area Code
Phone Number
Do you have a history of non-food addiction?
No
Yes
Have you had adverse (negative) childhood events?
No
Yes
Do you have a history of significant mental illness?
No
Yes
Have had any previous bariatric procedures?
No
Yes
What is your current weight in pounds?
What is your current height in feet and inches?
Current Mental Health Provider
If none indicate NA
Current Mental Health Provider Phone
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Area Code
Phone Number
Current psych medications and dosage
Please list history of psych treatments (talk or meds) and general outcomes
Insurance information
If you plan to use insurance, you probably will not need preauthorization for bariatric surgery with Premier Surgical, UT Bariatrics or New Life Bariatrics at Tennova. All others, please provide an MD referral for assessment and check with your insurance for pre-authorization.
Name of Insured if other than self
Please input name exactly as it appears on insurance card including initials and suffixes
Insured DOB
/
Month
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Day
Year
Date Picker Icon
Insured SS Number
Insurance Plan
*
Exactly as listed on insurance card including letters and dashes
Insurance Plan2
Exactly as listed on insurance card including letters and dashes
Insurance Plan3
Exactly as listed on insurance card including letters and dashes
Insurance ID Number
*
Exactly as listed on insurance card including letters and dashes
Insurance ID Number2
Exactly as listed on insurance card including letters and dashes
Insurance ID Number3
Exactly as listed on insurance card including letters and dashes
Insurance Provider Phone Number (on back of insurance card)
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Area Code
Phone Number
Insurance Provider2 Phone Number (on back of insurance card)
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Area Code
Phone Number
Insurance Provider3 Phone Number (on back of insurance card)
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Area Code
Phone Number
Authorization for Communications with Referral Source:
Authorization for Communication with Referral Source: My signature below indicates my pennission of G. Douglas Cox, Ph.D. and other treating providers to communicate verbally and/or in writing as they think necessary for the benefit of my treatment
Authorization for Communications Signature
*
Date
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Month
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Date
Assignment of benefits/release of information authorization
I request that G. Douglas Cox, PhD. file claims on my behalf with my insurance company for professional services rendered to me or to a member of my family. I authorize G. Douglas Cox, Ph.D.and/or his agent to contact my insurance company and /or managed care organization to verify my coverage and to obtain benefit information. I understand that my insurance company and /or managed care organization may require information about my treatment in order to process the claim, and that this includes diagnosis, background information and/or treatment plans. I further authorize G. Douglas Cox, Ph.D. and /or his agents to release this information to my insurance company and or managed care organization as needed to process those claims. I assign payment to G .Douglas Cox for services provided. This includes applicable benefits that would otherwise be payable tome. I understand that this amount is not to exceed the regular charge for services. I understand that I am financially responsible for any charges not covered by my insurance company (including all charges for missed appointments and cancellations with less that 24 hour's notice). Costs of collections services will be added to my account. I may revoke this release at any time in writing. Any release which has been made prior to the receipt of a written revocation and which was made in reliance upon this authorization shall not constitute a breach of my confidentiality. This release is good from the date below until my written revocation
Client Consent for Treatment
I, the undersigned, a.in the client or the client's duly authorized representative, and do hereby voluntarily consent to and authorize psychological care and treatment by G. Douglas Cox, Ph.D. this care and treatment encompasses all diagnostic and the therapeutic treatments considered necessary or advisable in the judgment of the provider. I have read and understand the policies described above. My signature below indicates my full and informed consent to treatment, my willingness to abide by the billing practices described, and my intention to be an active participant in my own therapy.
Treatment Consent Signature
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Date
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Year
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I have read the Adult Therapy Agreement and The HIPPA Notice and agree to provide sensitive information
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Date
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Desire to Follow-up
Pease answer the following questions if you think you would eventually like follow-up support
Are you willing to keep a quality of life journal?
No
Yes
Are you willing to report failures?
No
Yes
Will you provide us with information about your journey?
No
Yes
Can we share your information anonymously in a national research project?
No
Yes
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