Suboxone Follow Up Form With Payment Agreement

Altmed Medical Center

8551 Rixlew Lane Suite #140 A, Manassas, VA, 20109 | 11885 Holly Lane Suite 4, Woldorf, MD 20601 | 9816 Winchester Rd, Front Royal, VA 22630 | 7700 Little River Turnpike Suite 104 Annandale, VA 22003 Ph: (703) 361-4357 | Website: www.altmedfirst.com | Email: info@altmedfirst.com
Patient Name*
Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date

Tick the answer that best fits the way you feel now*

	(0)	(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	(10)
I feel anxious
I feel like yawning
I am perspiring
My nose is running and/or my eyes are watery
I have goose bumps and/or chi ls
I feel nauseated or like I may need to vomit
I have stomach cramps and/or diarrhea
My muscles twitch
I feel dehydrated and/or have not had much appetite
I am having difficulty sleeping
I have a headache
My muscles and bones ache
I feel like using right now
I would rate my overall level of withdrawal as

Do you feel you need a dosage change?

NoYes
If yes, select below to adjust the dosage

UpDown
Have you used alcohol or other drugs since your last visit?*

YesNo
If "yes," please describe what, when, and how much.
Please describe any life changes, triggers, or stressors that have occurred since your last visit.
Since your last visit have you relapsed?*

NoYes
(if yes, please specify which substance and when)
Have you attended any AA/NA meetings since your last visit?*

YesNo
Dates and Location
Have you established a support network? (family, non-drug using friends, spouse, significant other, etc.)*

YesNo
Who?
Medication Change
Any Medication Change?*

YesNo

Side Effects/Symptoms (please circle all that apply):*

FeverFluttering of the heartConstipationSedation (sleepiness)Abdominal painNauseaChillsDouble/Blurred visionDizzinessSweats.None
Explain other symptoms that you experienced which are not mentioned above, since your last visit:
Self How would you like to make Payment for the Medical Service?*

Self PayInsurance
Self Pay Agreement

You have registered as a private pay patient. This means at the time of the service you will be paying by cash, cheque or debit/credit card. Due to this cash payment you are receiving a discount. We will not bill insurance for service provided under this arrangement. No forms will be produced now, or in the future for you or us to submit for insurance billing.
I understand that the charges presented to me are due in full on the day of service, unless arrangements have been made with the Billing manager in advance
I understand that I will be responsible for all charge related to the services provided to me by Altmed Medical Center.
Signature*

Clear
Date*

MonthDayYear
Date
Insurance Information and Agreement
Primary Insurance Carrier*
Phone*
Please enter a valid phone number.
Insurance ID#*
Group #*
Name of Policy Holder*
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Date
Policy Holder's Address*
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Policy Holders Employer*
Employer Insurance Plan*

YesNo
Relationship of Patient to Policy Holder*

SelfHusbandWifeChildOther
Relationship*
I authorize my insurance benefits to be paid directly to the physician and I agree to be financially responsible for all charges incurred. I hereby consent to the release and redisclosure of my medical records to enable or facilitate the collection, verification or settlement of my account for any amounts due from me or any third-party payer, HMO or other health benefit plan. This consent applies to Altmed or any of its affiliates. I agree to pay for service rendered to me or the above-named patient at the time of services or the first statement mailed by Altmed. I promise to pay my account when due and should this account become delinquent and collection becomes necessary, the undersigned agrees to be responsible for attorney's fees of thirty-three and one third percent (33 1/3%), interest at eighteen percent (18%) per annum from the last date of payment and any and all applicable court costs. I further agree to pay for my any reasonable fees for missed appointments of which I did not notify the medical office at least 24 hours prior to your appointment.

In the event that a check is returned for insufficient fund you are responsible for $35.00 return fees. I * , as the financially responsible party to the above-named patient agree to the aforementioned statements and authorize payment of medical benefits to Altmed for services rendered.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

	Name	Dose	Frequency(Per Day)	Prescribing Doctor
1
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3
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5

Altmed Medical Center

Medication Change

Insurance Information and Agreement