Approved Patient Paper Work

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CRASMERE WEEKLY NEWSLETTER

Our goal is to start a newsletter that allows patients to be more informed with our offices. This newsletter will be emailed to you, under HIPPA regulations and your information will be kept in complete confidentiality. If you subscribe to this newsletter and decide at a later date that you do not wish to receive it any longer, you can simply unsubscribe to it. Please write your information below, with your signed consent, printed name and we will send you your newsletter.
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Email Consent* This field is required.
I agree to release my information to Crasmere Psychiatric Services to receive a weekly newsletter.
I do not agree to release my email to Crasmere Psychiatric Services to receive a weekly newsletter.
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Email* This field is required.I agree to release my email information to Crasmere Psychiatric Services to receive a weekly newsletter.
example@example.com
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Printed Name of the Patient* This field is required.
First Name
Last Name
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Relationship to the patient* This field is required.
Child
Self
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Signature of the Patient or Responsible Party* This field is required.
ClearSignature of Patient/Guardian
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Date* This field is required.
Date
Month
Day
Year
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Patient Name* This field is required.
First Name
Last Name
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Home Phone Number
Area Code
Phone Number
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Cell Phone Number* This field is required.
Area Code
Phone Number
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Email* This field is required.
example@example.com
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If child:

Father's Name: Fathers Name Mother's Name: Mother's Name
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Patient Information* This field is required.
Male
Female
Other
Sex
Age
Date of Birth :MM/DD/YYYY
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Family Physician Information* This field is required.
Family Physician/Pediatrician Name:
Family Physician/Pediatrician Address:
Family Physician/Pediatrician Phone:
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Patient Employed by (if child indicate school)* This field is required.
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Business Phone Number* This field is required.
Area Code
Phone Number
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Who referred you:* This field is required.
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Previously Evaluated?* This field is required.
YESNO
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If yes, where/by whom?* This field is required.
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Pharmacy Information* This field is required.
Pharmacy Name:
Pharmacy Phone:
Pharmacy Address
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Insurance Information* This field is required.
Primary Insurance Company:
Member ID#:
Holder of Insurance:
Relationship to Patient
Policy Holder Date of Birth
Social Security #
Policy Holder Address
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Insurance Information Continued* This field is required.
Policy Holder Employed by:
Business Phone:
Copayment:
Insurance Phone #:
Group #:
Contract #:
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Do you have Secondary Insurance?* This field is required.
Yes
No
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Secondary Insurance Information* This field is required.
Subscriber Name:
Relation to Patient
Insured's DOB:
Social Security #
Insurance Company
Subscriber
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Secondary Insurance Information Contd.* This field is required.
Copayment Amount
Insurance Phone #:
Group #:
Contract #:
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Insurance & Payment Contract

- I authorize release of information to all my insurance companies.

- I understand that information I give my doctor will be kept confidential, but my doctor is required by law to report evidence of child abuse.

- I understand that I am responsible for my bill.

- I understand that I am responsible for payment for any and all missed session for which I do not notify the doctor of the cancellation at least 24 hours in advance, a $40 fee will be charged to you, for a same day cancellation.

- Therapist appointments, there will be a $60 same day cancellation fee charged to you.
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Date * This field is required.
Date
Month
Day
Year
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Insurance & Payment Contract Signature* This field is required.
ClearSignature of Patient/Guardian
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RESPONSIBILITY FOR FEE
I, * , regarding patient understand that Crasmere Psychiatric Services, P.C. will submit claims to my insurance company for reimbursement. If these charges are not reimbursed by my insurance company, due to the services not being covered, prior approval from the insurance company not obtained due to my not informing the office that approval is necessary, my benefits being exhausted, my managed care sessions being used up, or any other reason that the insurance company does not pay for my visits, I realize that I am ultimately responsible for these charges.
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Responsibility For Fee Signature* This field is required.
ClearSignature of Patient/Guardian
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PATIENT ACKNOWLEDGEMENT

I hereby acknowledge that I have received a copy of the Notice of Privacy Practices of Crasmere Psychiatric Services, P.C.
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Patient Acknowledgement Information* This field is required.
Patient Name
Date: MM/DD/YYYY
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Signature for Patient Acknowledgement* This field is required.
ClearSignature of Patient (or authorized represenative)
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CONSENT TO EMAIL USE

As a supplement to your in-office appointments, we are inviting you to use email to communicate with our practice. Set forth below are policies outlining when and how email should be utilized to maintain your privacy and to enhance communication as well as a place for you to acknowledge your consent to its use. Your decision to utilize email is strictly voluntary and your consent may be rescinded at any time. Email will be accessed by Crasmere clinical provider or a staff member on a regular basis. You may expect any required response within 24 hours.

When may I use email to communicate with the office?

Email may be used to:

Appointment requests.

Other matters not requiring an immediate response.

When should I NOT use email to communicate with the office?

Email should never be used:

In an emergency.

I you are experiencing any desire to harm yourself or others.

If you are experiencing a severe medication reaction.

If you need an immediate response.

What are the risks of using email?

Risks of communicating via email include but are not limited to:

Email may be seen unintended viewers if addressed incorrectly.

Email may be intercepted by hackers and redistributed.

Someone posing as you could access your information.

Email can be used to spread computer viruses.

There is a risk that email may not be received by either party in a timely matter as it may be caught by junk/spam filters.

Emails are discoverable in litigation and may be used as evidence in court.

Emails can be circulated and stored by unintended recipients.

Statements made via email may be misunderstood thus creating miscommunication and/or negatively affecting treatment.

There may be an unanticipated time delay between messages being sent and received.

What happens to my messages?

Emails will be printed out and maintained as a permanent part of your medical record.

As part of your permanent record, they will be released along with the rest of the records upon your authorization or when the doctor is otherwise legally required to do so.

Messages may be seen by staff for the purpose of filing or carrying out requests (e.g., appointment scheduling).

What happens to my obligations?

I must let the doctor know immediately if my email address changes.

If I do not receive a response from the doctor in the time frame indicated (stated expected response time), I will contact him/her by telephone if a response is needed.

I will use email communication only for the purpose stated above.

I will advise the doctor in writing should I decide that I would prefer not to continue communicating via email.

I understand that the email may not only be used to supplement my appointment with the doctor and not as a substitute for them.

To avoid possible confusion, I will not use internet slang or short-hand when communicating via email.

What steps has Crasmere Psychitric Services, P.C. taken to protect the privacy of my email communication?

Set up a password-protected screen-saver on his computer.

Educated staff on the appropriate use and protection of email.

Does not access patient email from public Wi-Fi hotspots.

Will not transmit highly sensitive information via email.

Will not forward patient email to third-parties without your express consent.

Will verify email addresses before sending messages.

What steps can I take to protect my privacy?

Do not use work computer to communicate with the doctor as your employer has a right to inspect emails sent through the company's system.

Do not use a shared email account to transmit messages.

Log out of your email account if you will be away from your computer.

Carefully check the address before hitting "send" to ensure that you are sending your message to the intended receiver.

Avoid writing or reading emails on a mobile device in a public place.

Avoid accessing email on Wi-Fi hotspot.

Make certain that your email is signed with your first and last name and include your telephone number and date of birth to avoid possible mix up with same or similar names.
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CONSENT TO EMAIL USE
By signing below, I consent to the use of email communication between myself, * , and Crasmere Psychiatric Services, P.C. I recognize that there are risks to use its use, and despite doctor's efforts, he/she can not absolutely guarantee confidentiality. I understand and accept those risks and the policies for email use outline in the form. I further a free to follow these policies and agree that should I fail to do so, the doctor may cease to allow me to use email to communicate with him/her. I also understand that I may withdraw my consent to communicate via email at any time by notifying the doctor in writing.

Name of Patient/Guardian: *
Date: *
Email Address: *
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Signature for Consent to Email Use* This field is required.
ClearSignature of Patient/Guardian
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Patient Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
Date
Month
Day
Year
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Health History* This field is required.
Name:
Date: MM/DD/YYYY
Date of Birth: MM/DD/YYYY
Age
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Are you currently or have you ever been treated for: * This field is required.
Yes
No
Explain
Asthma
Bleeding Disorders
Blood Pressure
COPD
Diabetes
Ear/sinus
Fainting
Gastro-intestinal problems
Heart Disease
Kidney Disease
Learning Disorders
Menstrual Problems
Musculo-skeletal
Psychological/psychiatric
Seizures
Sickle cell disease
Sleep Disoerders
Stroke
Surgery
Thyroid Disease
SeriousInjury
Other
Asthma
Bleeding Disorders
Blood Pressure
COPD
Diabetes
Ear/sinus
Fainting
Gastro-intestinal problems
Heart Disease
Kidney Disease
Learning Disorders
Menstrual Problems
Musculo-skeletal
Psychological/psychiatric
Seizures
Sickle cell disease
Sleep Disoerders
Stroke
Surgery
Thyroid Disease
SeriousInjury
Other
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
Yes
No
Explain
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List all medications you are currently taking, include over-the-counter drugs and herbal supplements.* This field is required.
Medication
Dosage
Reason
Medication
Dosage
Reason
Medication
Dosage
Reason
Medication
Dosage
Reason
Medication
Dosage
Reason
1 of 4
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Allergies
Allergies
Allergies
Allergies
Allergies
Allergies
Allergies
Allergies
Allergies
Allergies
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Health History Signature* This field is required.
ClearSignature of Patient/Guardian
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Patient Name: First Name * Last Name *
I also hereby consent to the disclosure of my health information of the following purpose to provide diagnosis and treatment to my primary care physician for coordination of care.

Date *
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Coordination of Care Consent Signature* This field is required.
ClearPatient or Legal Representative Signature (Relationship)
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Primary Care Physician Information
Name: Name *
Address:     Address *
City: City *
State:
Zip: Zip *
Phone: Phonr *
Should be Empty:

CRASMERE WEEKLY NEWSLETTER

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