New Patient Forms HIPAA Compliant (Updated Sept 2025)

Assignment of Insurance Release
Please remember that insurance is considered a method of reimbursing the patient for fees paid directly to the provider and is not a substitute for payment. Some companies will pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is the patient's ultimate responsibility to pay any deductible amount, co-insurance, or any other balances not paid for by your insurance company. If we are filing your claim, we will allow forty-five days from the billing date for the carrier to process your claim and make payment accordingly. If payment from your insurance company is not received within the time frame specified above, we will notify you to clear your account. Filing to the insurance company is only done as a courtesy to the patient. I certify that I have read and understand fully the provider's billing policy and agree to make payment in full and /or satisfactory arrangements when asked to do so as specified above.

To the extent necessary to determine liability for payment and to obtain reimbursement, I authorize disclosure of portions of the patient's record. I hereby assign all medical and /or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, Private Insurance, and other health plans. This assignment applies to all charges outstanding as of the date of signature and will remain in effect for all current and future charges until revoked in writing. A photocopy of this assignment is to be considered as valid as the original. I understand that I am financially responsible for all charges whether paid or not by the insurance carrier. I hereby authorize said assignee to release all information necessary to secure payment. Should the account be referred to an attorney for collection, the undersigned shall pay reasonable attorney's fees and collection expense.

Our patient “Bill of Rights” and “Notice of Privacy Policies” are posted in the lobby of the office. We strongly encourage you to review these notices completely and ask any questions on areas that you do not understand. It is your responsibility to know and abide by both policies.
Signature*

Clear
Date*

MonthDayYear
Parent Signature (if minor)

Clear
Date*

MonthDayYear
I have read the information stated above and agree with the policies and procedures as presented.
Signed*

Clear
Date*

MonthDayYear
Consent to Examination and Treatment
I consent to have Piedmont Psychiatric Services including its professional staff perform/order examination(s), psychotherapy, related mental health treatments, and order/refill medications when deemed necessary. I also understand that Piedmont Psychiatric Services is a "learning facility" and a student may be present at my appointment.
Signature*

Clear
Date*

MonthDayYear

Responsible Party Information
*(Parent, Guardian, Power of Attorney) if any information is the same as above, please indicate by writing "same" in appropriate section.
Relationship to Patient*

SelfSpouseParentOther
Name*

First NameMiddle NameLast Name
Address*

Mailing Address

Street Address Line 2

City, State, Zip CodeState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Driver's License #*
Social Security Number*
Date of Birth*

MonthDayYear
Employer*
Employer Telephone #*
Please enter a valid phone number.
Employer's Address*
Occupation*
Email Address*
example@example.com
Please complete if the patient is under the age of 18
Father's Name

First NameMiddle InitialLast Name
Mother's Name

First NameMiddle InitialLast Name
Father's DOB

MonthDayYear
Date
Mother's DOB

MonthDayYear
Date
Father 's SSN
Mother's SSN
Legal Guardian

Release of Confidential Medical Information (HIPAA)
Patient Name*
Date of Birth*

MonthDayYear
I agree and consent that my current treatment notes be released to the following medical provider(s):I do not allow my current treatment notes be released to any medical provider(s).
Name of Doctor or practice name
Phone/Fax #
Please enter a valid phone number.
Name of Doctor or practice name
Phone/Fax #
Please enter a valid phone number.
I AGREE AND CONSENT THAT THE FOLLOWING FAMILY MEMBERS, SPOUSE or OTHER INDIVIDUALS:
Name
Relationship to patient
Name
Relationship to Patient
Name
Relationship to Patient
MAY receive the following information:*

Insurance & BillingAppointment Date & TimeDiscuss Treatment Plans (ex: medication)All of the aboveI do not wish to release any of my medical information to any individual
I understand that I may revoke this consent at any time except to the extent that the action has been taken based on this authorization. I also understand that this authorization shall not expire unless I revoke it in writing.
Signature of patient or Legal Guardian*

Clear
Date*

MonthDayYear
Witness*

Clear
Date*

MonthDayYear
If this release pertains to alcohol or drug abuse information, please note that: This information is protected by federal law. Federal regulation (42c F.R. Part 2) prohibits you from making further disclosure of it without specific written consent of the patient whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose.

Controlled Medication Agreement
Patient Name *
Should the providers of Piedmont Psychiatric Services, P.A. and I decide that a controlled medication is the appropriate course of treatment, I understand that I will be required to abide by the following policies:

I will take all medications as prescribed. I understand that the controlled medication will be prescribed ONLY by Piedmont Psychiatric Services, P. A. and ONLY according to the agreed upon schedule.

Prescription refills for the above medications will be provided only during regularly scheduled business hours and never on weekends, holidays, or after hours.

I understand that lost or stolen medications will not be filled under any circumstances. It is my responsibility to protect and secure any medications. This includes keeping the medication out of reach of children and animals.

Should I require anxiety medications, I will not take any sedative, alcohol, or pain medications without the approval of my psychiatrist. I will not seek or accept any medication for anxiety other than those prescribed by Piedmont Psychiatric Services, P. A. “Medications for anxiety” include prescriptions from other doctors, medications borrowed or accepted from family and friends and any illicit or street drugs.

I understand that Piedmont Psychiatric Services, P. A. is under no obligation to provide these medications to me and that we reserve the right to discontinue these medications at any time. At my psychiatrist’s discretion, I agree to cooperate with random drug testing which may be required at any time. If I refuse, I understand the medication will be discontinued and I may be discharged from this practice.

I agree to obtain anxiety medications from only one provider. I will not give, sell or in any way distribute prescribed medications to any other person (s). I will not, in any way, attempt to forge or alter a prescription.

I agree to fill prescriptions for controlled substances at the pharmacy I list below. If I change pharmacies, I will need to contact Piedmont Psychiatric Services, P. A. and provide them with the name, address, and phone number of the new pharmacy.

I understand that lost or stolen medications will not be filled under any circumstances. It is my responsibility to protect and secure any medications. This includes keeping the medication out of reach of children and animals.

Should I require anxiety medications, I will not take any sedative, alcohol, or pain medications without the approval of my psychiatrist. I will not seek or accept any medication for anxiety other than those prescribed by Piedmont Psychiatric Services, P. A. “Medications for anxiety” include prescriptions from other doctors, medications borrowed or accepted from family and friends and any illicit or street drugs.

I understand that Piedmont Psychiatric Services, P. A. is under no obligation to provide these medications to me and that we reserve the right to discontinue these medications at any time. At my psychiatrist’s discretion, I agree to cooperate with random drug testing which may be required at any time. If I refuse, I understand the medication will be discontinued and I may be discharged from this practice.

I agree to obtain anxiety medications from only one provider. I will not give, sell or in any way distribute prescribed medications to any other person (s). I will not, in any way, attempt to forge or alter a prescription.

I agree to fill prescriptions for controlled substances at the pharmacy I list below. If I change pharmacies, I will need to contact Piedmont Psychiatric Services, P. A. and provide them with the name, address, and phone number of the new pharmacy.

Under no circumstance will I obtain medications for controlled substances from more than one pharmacy or Physician at a time.
Pharmacy Name*
Pharmacy Address*
Pharmacy Phone #*
Please enter a valid phone number.
I understand that by signing this agreement, I must abide by the rules above and that failure to abide by this agreement will result in termination of services from Piedmont Psychiatry.
Patient Signature*

Clear
DATE*

MonthDayYear
* AGREEMENT MUST BE SIGNED OR NO CONTROLLED MEDICATIONS WILL BE GIVEN *

TELEHEALTH Informed Consent
I agree to participate in technology-based health care related visits to exchange healthcare information and treatment with the providers of service at Piedmont Psychiatric Services PA. I understand and authorize information of my medical record to be electronically transmitted in the form of images and data through an interactive video connection to and from the above-named provider. It may also mean that my private health information may be transmitted from my providers mobile device to my own or from my device to that of my provider via an application.

I understand that a variety of alternative methods of healthcare may be available to me and that I may choose one or more of these at any time. My healthcare provider has explained the alternatives to my satisfaction.

I represent that I am using my own equipment to communicate and not equipment owned by anyone else. I understand that I can never use my employer’s computer or network systems. I understand that any information that I enter into any employer’s computer can be considered by the courts to belong to my employer and my privacy may be compromised.

My provider has explained how the telehealth sessions will be performed and how they may differ from in person services.

I understand that telehealth services have potential risks. An example is that the technology could fail before or during the visit. In that case I understand that I will be allowed to call my provider and be connected telephonically to continue my visit.

While security protocols are in place to protect the confidentiality of client information transmitted via electronic channel, I understand that in rare instances, security protocols could fail, causing breach of privacy of personal health information.

I have been informed of any cost differences for services provided in person versus through technology.

Below are the names and telephone numbers of my local emergency contacts:
Name
Relationship
Telephone #
Name
Relationship
Telephone #
Patients Printed Name
Signature of Patient or Guardian

Clear
Date

MonthDayYear
Date
Printed Name of Person Signing

OFFICE INFORMATION

OFFICE HOURS
Our office hours are 8:00 am - 4:00 pm Mon-Thurs. Our office is closed on Fridays.

APPOINTMENTS
*Appointments may be scheduled by calling our appointment line at 864-676-9211 ext. 125 or email at appointments@piedmontpsych.com between the hours of 8 am-4 pm M-Thurs.

PATIENT CONCERNS/QUESTIONS

*Patients of Dr. Smith, Joey Friddle and Sydney Broxton contact their assistant Niki at physicians@piedmontpsych.com or phone 864-676-9211 ext. 140.

*Patients of Dr. Goodbar and Carrie Ballenger contact their assistant Revonda at revonda@piedmontpsych.com or phone 864-676-9211 ext. 138.

*For Therapists contact appointments@piedmontpsych.com or phone 864-676- 9211 ext. 125.

*After hours calls/weekends are for emergencies only. In this case, calls are taken by the answering service and then forwarded to the physician on call. There is a $15 charge for after hour calls.

*After hours calls/weekends are for emergencies only. In this case, calls are taken by the answering service and then forwarded to the physician on call. There is a $15 charge for after hour calls.

MEDICATIONS/REFILLS
*Medication refills can be obtained during office visits or by calling/emailing the medical assistants with your specific request and pharmacy number. No controlled medications are sent in after hours or weekends.

CORRESPONDENCES/FORMS
*Requests for Medical Records dictated letters, and forms (i.e., disability, return to work statements, etc.) can be obtained for a variable charge. Contact Terri at triddle@piedmontpsych.com or phone 676-9211 ext. 126.

BILLING/INSURANCE
* Mon-Thurs. 8:00am-4:00 pm at 1-855-558-4649. We submit claims for up to 2 insurances. Any payments not made at the time of service, will incur a $15 non-payment fee and no scheduled appointment.
Should be Empty:

	Yes	No
Cannot Sleep
Sleeping Too Much
Loss of Appetite
Recent Weight Loss
Increased Appetite
Recent Weight Gain
Loss of Energy
Loss of Motivation
Loss of Interest in Pleasurable Activities
Decreased Interest in Sex
Difficulty Concentrating
Feelings of Hopelessness
Suicidal Thoughts
Frequent Crying Spells
Too Much Energy
Racing Thoughts
Periods of Quick Anger or Agitation
Periods of Excitement or Elation
Overspending Money
Anxiety Attacks
Recurrent or Repetitive Thoughts or Worries
Repetitive Behaviors or Rituals
Hearing Voices
Seeing Things that Others Do Not See
Paranoid Feelings of Suspiciousness

	Not at all	Several Days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

	Not at all	Several Days	More than half the days	Nearly every day
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid, as if something awful might happen

Assignment of Insurance Release

Consent to Examination and Treatment

Patient Information

Responsible Party Information

Release of Confidential Medical Information (HIPAA)

Mental Health Checklist

Areas of Stress

General Information

Controlled Medication Agreement

TELEHEALTH Informed Consent

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

GAD-7 Anxiety