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 12735 Meeting House Rd., Suite 200, 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 ADHD Objective Testing and describe any concerns you have, risk factors etc.

Have you discussed concerns with your primary care doctor?

Who is referring you for testing?

Other

Do you have a family history of ADHD?

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

Are you currently on medication for ADHD?

Have you ever been diagnosed or treated for any of the following?

Are you currently taking other medication for mental health?

How did you hear that QbTesting/Objective Testing was available at our office?

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.

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 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 unless requested (for an additional fee) just to review data.

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 and CNS Vital Signs 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 $350 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. You will also be asked to complete CNS Vital Signs Remote testing (takes up to 1 hour) on your own.

Dr Bauer will then review the results of both tests 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 CNS Vital Signs report and QbTest data and Dr Bauer will fax your PCP or adult mental health provider the interpretation report with all the data within 7 business days of taking the test and it will be sent to your CHARM portal.

Once the consent form is completed, you will get an email from Amy Barnes with instructions to activate the CHARM portal and to schedule your appointment for the QbTest. You will get further instructions of when to complete the CNS Vital Signs assessment at home/work. If you do not see an email from Amy after submission in your inbox within 48 hours, please check junk/spam folders or call our office at 765-534-7007.

Signature

Date Signed

Date

Medical Consent Form