New Patient Registration Form

Personal Information:

Date/Time of Registration

Patient Name:

First NameMiddle NameLast NameSuffix

Date of Birth:

MonthDayYear

Age:

Gender:

Sexual Orientation:

(heterosexual/straight, asexual, lesbian, gay, bisexual, transexual, queer, polysexual, pansexual, etc)

Relationship Status:

Cell Phone Number

Format: (000) 000-0000.

E-mail for Appt. Reminders

example@example.com

Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employment Status:

Primary Care Provider:

Name of MD/NP/PA/ or None

Primary Care Provider Telephone #:

Telephone Number / None

Primary Care Provider:

Therapist/Counselor:

Name / None

Therapist / Counselor Telephone #:

Telephone Number / None

Therapist / Counselor:

Which medical conditions do you have (check any that apply)?

List any Medications or supplements you are currently taking, even any over the counter products:

Do you have any Allergies to food or medications?

If yes, then name your allergies:

Have you had any minor or major surgeries?

If yes, then name past/upcoming surgeries?

(Appendectomy, Gallbladder, Cancer, Cesarean Section, Bariatric, Plastic/cosmetic surgery, etc)

Brief Psychiatric History

Have you ever been psychiatrically hospitalized?

Name the hospital, year, and reason you were psychiatrically hospitalized in the past:

Have you ever self-harmed or tried to hurt someone else?

Have you ever attempted suicide?

Do you own or have access to a firearm/gun?

Have you used or abused illicit substances or prescription medication(s)?

Do you currently smoke or vape any substances?

Do you have a history of any Legal issues?

Insurance Information:

Deductible Terms: On the day of the appointment all deductible policies are required to pay the required amount.

Copay Terms: All Copays are due at time of the appointment. I accept Zelle, Venmo, Cash, or Personal Check payments. For HSA card holders, I can provide reciept for copayments paid via above method.

*We do not take any responsibilty for failed reimbursements by your insurance company.

Type of Payment

Name of Policy Holder (Parent/Spouse/Self):

First NameLast Name

Policy Holder's Date of Birth:

Address of Insurance Policy Holder if different from Home Address (above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance Plan:

Other Policy name:

Name of Policy not listed above

Insurance Policy #:

Insurance Group #:

Copayment amount:

Deductible amount:

Upload Photo of Insurance Card (front and back):

Review practice policy and Acknowledge:

Emergencies

In addition to my regular office hours (Fridays), my practice has limited coverage. In case of psychiatric emergencies such as suicidal and homicidal ideations/attempts, please contact 911 or parents/guardian must call 911 for immediate help/rescue according to safety plan. Please do not contact via text, email, or voicemail during a patient emergency. I can make time for any urgent patient matters in a timely manner and will be available to help you during my hours of Preferred Call Time (9am-10pm) only. If I am not available, please go to the nearest emergency room, call your therapist, or contact your general physician/primary care physician's office for immediate medical attention.

Office Visit Policy

All patients will be required to present a valid insurance card (if applicable) and driver's license or photo ID, and payment will be collected at every office visit prior to being seen by the physician.

Refill Policy

Please understand I will honor all refill requests via email or telephone in 48 hours, so please be aware that you will need to call 7 days prior to your "running out" of your medication to obtain this quick response. Otherwise, the expectation is to see your provider by scheduling an appointment to obtain a refill, or obtain a short medication supply from your general physician.

Payment Policy

Payment will be requested at the time of service for all services that are non-covered or determined to be the patient's responsibility, including co-payments. Payment may be made through Zelle, Venmo, or Cash (PERSONAL CHECKS MAY NOT BE ACCEPTED ALWAYS). For HSA Benefit card holders, you may pay using above method and ask for reciept of payments to submit at the end of the year. My fees are comparable to the usual and customary fees charged by other Behavioral Health physicians/practices in this area.

Insurance Claims/Billing

Binu Chacko MD PC, participates with some major insurance carriers. As a courtesy to our patients, I will file insurance claims for those insurances with which I participate. Please remember, any amount not covered by insurance is ultimately the patient's responsibility. A list of the major insurance companies we participate with is on this website, but please contact your insurance company to confirm that we are still participating. We require that you bring your insurance card and photo ID to all visits. Patients with Medicaid, Managed or Third party medicaid programs are not accepted to the practice currently. Clients seeking Disability or Temporary disability evaluations are also not accepted.

Appointment Cancellation Policy

Please call 24 hours before your office visit to cancel an appointment. If you are rescheduling an appointment, please let me know so that I can cancel it and open the time for another patient. You will be assessed a missed appointment fee of $75.00, if you cancel on the same day as your appointment, or miss an appointment completely. Also please keep in mind that 3 consecutive cancellations will be considered as noncompliance/No show equivalent and 2 or more No shows will be grounds for termination of treatment. Once discharged or terminated from practice you will not be accepted back.

I agree the above is reviewed and also accurately reported information and by signing my name, I affirm my acknowledgement of practice policy by Binu Chacko MD. PC.

Signature. (Self/ Minors: Parent/Guardian)

Patient Consent/Contract for Treatment:

As a participant in treatment for medications and/or therapy, I freely and voluntarily agree to accept this treatment contract as follows:

1. I agree to keep and be on time to all my scheduled appointments.

2. I agree to adhere to the payment policy outlined by this office. Payments must be made via cash, check, Venmo, or Zelle.

3. I agree to conduct myself in a courteous manner in the doctor's office.

4. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.

5. I agree not to deal, steal, or conduct any illegal or disruptive activities in the doctor's office.

6. I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my medications are filled, that the behavior will be reported to my doctor's office and could result in my treatment being terminated without any recourse for appeal.

7. I agree that my medication/prescription can only be prescribed to me at my regular office visits. A missed visit may result in my not being able to get my medication/prescription until the next scheduled visit.

8. I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of why it was lost.

9. I agree not to obtain medications from any doctors, dentists, pharmacies, or other sources without telling my treating physician.

10. I will let my physician know of all medications that I am being currently prescribed including those given by other treatment providers.

11. I agree to take my medication as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor.

12. I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as discussed and agreed upon with my doctor and specified in my treatment plan.

13. I agree to abstain from alcohol, opioids, cocaine, and other addictive substances as it may interfere with treatment (including nicotine and marijuana smoking/vaping in most cases).

14. I agree to provide random urine samples, saliva testing, or lab testing (if requested) and have my doctor test my blood alcohol level.

15. If there is a problem and the patient cannot make the scheduled appointment please call the office and leave a message. Failure to contact the office and not showing up at the scheduled appointment may result in a $75.00 fee that will be assessed at the following visit.

16. We do not take any responsibility for any failure of Insurance Reimbursements. You will be billed for any balances you are responsible for.

17. You must let your provider or the staff know of any changes in your insurance policy, otherwise you will be responsible for the charges incurred.

18. If you have not been compliant with your treatment visits for a period of 90 days, your case will be considered closed/inactive and be terminated from treatment of which we will send you a notification soon after the 90th day.

19. If you are terminated from the practice you will not be able to reschedule with our practice. You will be referred to other providers who provide similar services.

20. I understand that violations of the above may be grounds for termination of treatment.

I agree the above is reviewed and also accurately reported information and by signing my name, I affirm my acknowledgement of Contract for Treatment by Binu Chacko MD. PC.

Signature (Self/ Minors: Parent/Guardian)

Financial Policy Waiver/Policy:

We recommend your call your insurance company prior to rendering services from Binu Chacko MD. PC. or any of its clinicians, to avoid such issues as not being reimbursed for your visits or to all ensure we are a covered and paneled provider under your insurance company.We are committed to providing you the best possible care. If you have medical insurance we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding. We will file your insurance claim with your primary insurance for you, however we ask that you pay any co-payment or deductible at the time services are rendered and the balance in full if your insurance has not paid in 60 days. For insurance co-payment we accept Cash, Zelle, Venmo, and personal checks. We do process HSA Benefits credit card for copayments. We will do all we can to expedite insurance reimbursement, but you must realize that:

1. Your insurance is a contract between you, your employer and the insurance company. If we participate with your insurance plan, we are under contract to only charge what your company allows. Since each carriers "usual and customary" fees differ, we will take the appropriate discount when your insurance company pays our practice.

2. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. These non-covered services are your responsibility. We must emphasize that as Medical Care Providers; while the filing of insurance claims is a courtesy we extend to our patients, all charges are your responsibility from the date the services are rendered. We realize that temporary financial problems may affect payment of your account. If such problems arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about any of our financial policies, or any uncertainty regarding insurance coverage, please do not hesitate to ask. We are here to help you.

ASSIGNMENT OF INSURANCE BENEFITS & ACCEPTANCE OF FINANCIAL RESPONSIBILITY

I authorize the direct payment of any medical benefits to Binu Chacko MD. PC., for services rendered. I understand I am responsible for any and all usual and customary charges not paid as a result of this assignment. If the account is turned over to a third party, collection agency, or attorney, I understand a 10% service charge (Minimum of $15) will be added to the balance, and I understand I will be responsible to pay all litigation expenses, court costs, and reasonable attorney's fees.

I agree the above is reviewed and also accurately reported information and by signing my name, I affirm my acknowledgement of Financial Waiver/Policy.

Signature (Self/ Minors: Parent/Guardian)

Any comments, or Further Statements:

If you do not see a GREEN CHECK MARK screen after submitting the form, then scroll up on the form to make sure all fields are completed. You may enter 'none' or '0' for data that you cannot enter in any of the highlighted field.