ADHD Computerized Test (Parent/Adult) Consent Form

This form is intended for individuals who are >18 years of age who are NOT a patient of Dr Nerissa Bauer's practice.

QbTesting is conducted at 2159 Glebe Street, Suite 270, Carmel, IN 46032 in the Village of West Clay.

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Sex*

Primary Care Physician and Practice Name *

Phone Number of Primary Care Physician*

Please let us know your reasons for seeking out QbTesting and describe any concerns you have, risk factors etc.

Who is referring you for testing?

Primary care providerPsychiatrist or therapistSelf-referralOther

Have you ever been formally diagnosed with ADHD by a physician, psychologist or other certified mental health professional?

YesNot yet but suspected or have concerns

Are you currently on medication for ADHD?

Yes (if YES, please bring medicine(s) or write down the name and strength and bring this information with you to the appointment).No

How did you hear about QbTesting with Dr Nerissa Bauer?

If you are on medication for ADHD, many times doctors or providers want to have the QbTest done to check medication efficacy. Therefore, please make sure to schedule the test when you know that the medicine is still in your system.

Make sure to check with the referring provider (or your primary care doctor) if they feel comfortable getting an interpretation report from Dr Bauer or whether they need you to see an adult mental health specialist.

The referring provider/primary care doctor feels comfortable reviewing the results with me so just send the interpretation reportThe referring provider/primary care doctor does NOT feel comfortable reviewing the results so I will need a referral to an adult mental health specialist

Notice that Dr. Nerissa Bauer is a behavioral pediatrician and ADHD Specialist for Children/Teens.

This single visit does not constitute or establish a doctor-patient relationship. There is no follow up provided after the ADHD Computerized Testing for a parent/adult and it is expected and understood by both parties that the adult will complete all appropriate medical follow up, including sharing the ADHD Adult Screener and QbTest report, with their own primary care physician or mental health specialist such as a psychiatrist of their choosing. There will be no follow up visits after this testing appointment with Dr Bauer.

Dr. Bauer will not make an official diagnosis based on results obtained after testing. Adult ADHD requires additional history taking and other potential workup based on your medical history that your primary care doctor or specialist may want after seeing the QbTest results. If you need a referral to an adult mental health professional please let our office know so we can send you some recommendations.

What to Expect:

The TOTAL COST will be $185 for the test plus a report back to the referring provider or a mental health specialist of your choosing (referrals can be given by Dr Bauer) and payment is due upon conclusion of the testing. You will be asked to put a credit card on file when scheduling your test time. You will get a superbill PDF and receipt in the BILLING tab of CHARM that you can download and submit to your insurance provider.

You will get an email from Dr Bauer with instructions on how to activate the CHARM portal which will allow you to select an appointment time.

Testing will take appropriate 20 minutes but plan on 45 minutes in the office with our QbTest technician, Amy Barnes.

Dr Bauer will then review the test and create a report for your primary care doctor (or certified adult mental health provider of your choosing). You will get a copy of the summary report and Dr Bauer's interpretation report within 3 business days of taking the test and it will be sent to your CHARM portal.

Possible add on: If you would like to meet with Dr Bauer to review the test findings, there is a separate charge (an additinal $150 for half hour). Just let Dr Bauer know that is your preference.

Once the consent form is completed, you will get an email from Dr. Nerissa Bauer with instructions to activate the CHARM portal and then schedule your appointment for the QbTest. If you do not see it in your inbox, please check junk/spam folders. You will also have an ADHD Adult Screener form to complete and bring on the day of your QbTest to give to Amy.

Signature

Date Signed*

Date

Medical Consent Form