NEW PATIENT CONTACT INFORMATION

If you have a life threatening emergency please dial 911 or go to the nearest emergency room. Some other possible sources of care are listed below.

YOU MUST HAVE AN ACTIVE PRIMARY CARE PHYSICIAN AND ACTIVE INSURANCE WHICH COVERS LAB SERVICES TO ESTABLISH WITH THIS OFFICE. DO NOT COMPLETE THIS INTAKE IF YOU DO NOT.

ALSO, OUR RELATIONSHIP WITH MEDICARE IS LIKELY CHANGING IN THE NEXT SIX MONTHS. WE WILL LIKELY BE CHANGING FROM A PARTICIPATING TO A NON-PARTICIPATING PROVIDER.

WHAT DOES THIS MEAN?

WE STILL ACCEPT MEDICARE PATIENTS.

BUT...PATIENTS ARE REQUIRED TO PAY IN FULL FOR THEIR VISITS...AND THEN BE REIMBURSED BY APPROPRIATE AMOUNT BY MEDICARE OR THEIR INSURANCE.

FOR EXAMPLE:

IF YOU WERE SEEN FOR A HIGH LEVEL VISIT (SEE FEE SCHEDULE FOR FULL DETAILS) YOU WOULD HAVE TO PAY SOMETHING CLOSE TO $194.79. WE OR YOU WOULD THEN SUBMIT YOUR CLAIM TO YOUR INSURANCE AND THEY WOULD SEND YOU A CHECK FOR SOME PORTION OF THIS. FOR STRAIGHT MEDICARE IT WOULD NORMALLY BE 50-80% OF THIS CHARGE. BUT IT MIGHT TAKE SOME TIME TO GET PAID.

SO...THIS IS PROBABLY NOT THE RIGHT OFFICE FOR YOU IF YOU CANNOT AFFORD THE UP FRONT PAYMENTS OR IF YOU HAVE DIFFICULTY NEGOTIATING WITH YOUR OWN INSURANCE COMPANY BECAUSE IF THERE IS A PROBLEM, YOU WILL MOST LIKELY HAVE TO DO MOST OF THE WORK WITH YOUR INSURANCE COMPANY.

We understand that some patients would like to get in quickly and want to notify you as soon as possible whether we will be able to assist you.

We will review this submission within the next three days.

If you do not receive an email, voicemail or text within three days then, after review of submission, it has been determined that we are unable to assist you at this time. You may resubmit this form in three months to see if we have greater availability or new resources to help.

YOU ARE STILL NOT CONSIDERED AN ACTIVE PATIENT OF THIS OFFICE UNTIL AFTER YOUR FIRST FACE-TO- FACE VISIT WITH DOCTOR GRACE WHEN BOTH OF YOU AGREE TO ENTER INTO A DOCTOR-PATIENT RELATIONSHIP.

We are IN-NETWORK with the following insurances and able to verify benefits the fastest.

1. Medicare
2. Aetna Insurance- [Majority of Policies IN-Network Including -Strategic Resource Company- [ Aetna Specialty Group Insurance]
3. Cigna Insurance
4. Cigna Great West
5. Tri Care Humana Military Policies
6. ChampVa-
7. GEHA

We are out-of-network with all other insurances and the verification of benefits can take considerable time, up to a month depending on the policy and current staff availability.

In addition, the following plans generally have limited out-of-network benefits and end up being largely self-pay. Keep in mind that psychiatric care tends to be very expensive (often several thousand dollars over the first months of treatment). It is usually much more cost-effective to see a provider within your insurance.

1. BCBS Primary Insurance Policies [ All Policies]

2. FHCP-Medicare Advantage Plans- Affiliate of BCBS

3. Freedom, Insurance [ All Plans]

4. Ultimate Insurance [ All Plans]

5. Beacon Health Options [ All Pland]

6. Magellan Health- [ All Plans]

7. Optimum Healthcare

8. WellCare Insurance

ARE YOU A PREVIOUS PATIENT OF DR. GRACE?*

YESNO

Name*

First NameLast Name

PLEASE ENTER DATE OF BIRTH OF PATIENT. WE DO NOT SEE PATIENTS UNDER 18 YEARS OF AGE.

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

EMAIL AND TELEPHONE SECURE AND PRIVATE CONTACT*

EMAIL AND TELEPHONE-You may contact and leave private information including patient link and portal information via email and telephone. This includes my consent for reminders and telemedicine.NO PRIVATE INFORMATION- I do not wish to communicate any private information via email or telephone including telemedicine. Please just call me to schedule an appointment to do everything in the office.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What are your reasons for seeking mental health care at this time? (Select all that apply)*

ABILITY TO COME TO OFFICE/ACCESS CARE*

EASY- I can EASILY come to the office for routine appointments.DIFFICULT - Due to other constraints (health, financial, social) it is DIFFICULT for me to come to the office. I strongly prefer TELE-HEALTH visits whenever possible.

ABILITY TO ACCESS/USE TECHNOLOGY/INTERNET*

EASY- I can EASILY access the internet for my health care with a high-speed connection. This includes accessing of websites, portals, filling out online forms, and connecting to providers.DIFFICULT - Due to constraints (health, technology, social) it is DIFFICULT for me to access the internet for my health care. I strongly prefer as much communication as possible be in-person, via telephone, or through the mail.

TIMES NEEDED FOR IN-OFFICE APPOINTMENTS (CHECK ALL THAT YOU CAN DO. IF WE DO NOT HAVE AVAILABILITY IN YOUR "NEEDED" TIMES YOU WILL NOT BE SCHEDULED.)*

I AM AVAILABLE FOR ALL TIMES BELOW IF REQUIRED.EARLY MORNING WEEK-DAY APPOINTMENTS (7:30a.m.-9:00 a.m.)EARLY MORNING WEEKEND APPOINTMENTS (7:30a.m.-9:00 a.m.)LATER APPOINTMENTS (9:00a.m.-Noon)

YOU MUST HAVE AN ACTIVE PRIMARY CARE PHYSICIAN (YOU HAVE SEEN IN LAST YEAR) AT THIS TO ESTABLISH WITH THIS OFFICE. WHO IS YOUR CURRENT PRIMARY CARE PHYSICIAN? PLEASE PROVIDE A PHONE NUMBER AS WELL TO ALLOW US TO VERIFY YOUR STATUS WITH THEM.*

YOU MUST HAVE HEALTH INSURANCE THAT COVERS LABORATORY AND IMAGING SERVICES. WHO IS YOUR CURRENT PRIMARY INSURANCE PLAN (INCLUDE FULL PLAN NAME, POLICY NUMBER, GROUP NUMBER, NAME OF MAIN BENEFICIARY) AND CONTACT INFORMATION TO VERIFY.*

SECONDARY INSURANCE, IF APPLICABLE (INCLUDE FULL PLAN NAME, POLICY NUMBER, GROUP NUMBER, NAME OF MAIN BENEFICIARY)..IF NONE WRITE "NONE"*

WHAT ARE YOUR CURRENT MEDICATIONS AND DOSES? Type "none" if none.*

MAY WE VERIFY ANY CONTROLLED PRESCRIPTIONS ABOVE AS ACTIVE BY CONTACTING THE FLORIDA DRUG ENFORCEMENT AGENCY?*

YESNO

If you have out-of-network insurance, how would you like to proceed?*

Please verify my benefits prior to scheduling, I understand this may take considerable time if I am out-of-network.I am willing to be self-pay initially. Any insurance credits received will be returned to me once benefits are verified. I understand that self-pay psychiatric care can be very expensive (up to thousands of dollars the first several months) depending on my clinical needs.

NOTE
WE MAY NOT BE ABLE TO ACCEPT YOU AS A PATIENT.

THERE ARE MANY POSSIBLE REASONS FOR THIS:

WE MAY NOT HAVE ENOUGH AVAILABILITY CURRENTLY TO ASSIST WITH THIS ISSUE.

THERE MAY BE A CONFLICT OF INTEREST.

IT MAY BE OUTSIDE OUR EXPERTISE

THIS NON-ACCEPTANCE MAY OCCUR AFTER THIS PAPERWORK, THE INITIAL PAPERWORK, OR INITIAL VISIT. YOU ARE NOT A PATIENT OF THIS OFFICE UNTIL BOTH YOU AND DOCTOR GRACE AGREE TO ENTER INTO A DOCTOR-PATIENT RELATIONSHIP AFTER YOUR FIRST VISIT.

We will review this information and reach out to you within three days. If you have not received an email or heard from a member of the staff within seven days then we are unable to accomdate you at this time...please try again in 3 months as we attempt to expand our services.

Other options for care include the following:

Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255)

Citrus County Lifestream Crisis Line: 866-355-9394

Veteran Crisis Line: 1-800-273-8255. (Text 838255)

Local Urgent Psychiatric Services

The Vines Psychiatric Hospital

24 hour Emergency care and Hospitalization

866-671-3130

https://thevineshospital.com/
3130 Southwest 27th Ave. Ocala, FL 34471

Springbrook Psychiatric Hospital

24 hour Emergency care and Hospitalization

352-600-3288

springbrook hospital

7007 Grove Road, Spring Hill, FL

Lifestream Behavioral Center

Medication, therapy and 24 hour Emergency care and Hospitalization

866-355-9394

lifestream behavioral center

BY YOUR SIGNATURE BELOW YOU AGREE TO THE FOLLOWING:

1. I am NOT currently a danger to myself or others. Emergencies should be dealt with by contacting 911 or presenting to the nearest emergency room. The Vines in Ocala, Springbrook Hospital, Shands Hospital.

2. I have insurance that allows me to receive labs and imagining and I have an active primary care physician that will assist in my care should medical needs arise.

3. I understand that Dr. Grace will likely be moving to a "NON-PARTICIPATING PROVIDER" with medicare in the near future and am willing to pay in full at time of service under the provisions marked above.

4. THAT INFORMATION PROVIDED IS THE BEST TO MY KNOWLEDGE AND I NEED TO FOLLOW ALL INSTRUCTIONS TO OPTIMIZE MY HEALTH CARE FAILURE TO DO SO MAY RESULT IN INCREASE RISK OF SERIOUS ADVERSE EFFECTS.

*

Clear