NEW PATIENT CONTACT INFORMATION

If you are having an urgent mental health need please contact your primary care, local hospital, or 911.

Fill this paperwork first to establish with the office. After we review it, if we are able to schedule at this time, you will receive a password you can use to complete the entire new patient paperwork here:

NEW PATIENT PAPERWORK (PASSWORD REQUIRED)

IF YOU DO NOT HEAR FROM US WITHIN ONE WEEK, THEN WE ARE UNABLE TO ACCOMODATE YOU AT THIS TIME. PLEASE CONTACT OUR OFFICE IN SIX MONTHS TO SEE IF OUR SITUATION HAS CHANGED.

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?

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.Format: (000) 000-0000.

Email

example@example.com

EMAIL AND TELEPHONE SECURE AND PRIVATE CONTACT

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

ABILITY TO ACCESS/USE TECHNOLOGY/INTERNET

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.)

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.

OFTEN HAVING A TRUSTED SOURCE OF INFORMATION IS VALUABLE IN MENTAL HEALTH CARE. IS THERE A PERSON YOU WOULD LIKE TO BE INVOLVED IN YOUR CARE. SHARED INFORMATION WITH ETC. SOMEONE TO ASSIST IN MEDICATION AND DIAGNOSIS? IF NOT, WRITE "NONE"

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.

YOU MUST HAVE ACCESS TO YOUR FORMULARY OF MEDICATIONS IN ORDER TO RECEIVE TREATMENT HERE FOR US TO KNOW WHICH MEDICATIONS YOUR INSURANCE APPROVES. IF THERE IS AN ONLINE LINK TO YOUR FORMULARY PLACE IT HERE. OTHERWISE TYPE "I WILL BRING IT TO MY FIRST APPOINTMENT."

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?

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

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. 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.