NP FORM - 18 & Up

Welcome to Medpsych Integrated!

Please READ before completing form. We DO NOT offer therapy, only medication management.
Patient Name*

First NameLast Name
Preferred Name
Preferred Pronoun*

He/HimShe/HerThey/ThemUnknown
Date of Birth*

MonthDayYear
Date
Administrative Sex*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have insurance?*

YesNo
Self Pay Patients:

New Patient Evaluation: $300

40 minute follow up: $200

20 minute follow up: $150

Patients who do not have insurance at the
time of service will be considered self-pay.

Payment for each visit must be made in full at each visit.
Please note the following:

Medpsych Integrated, PLLC only files with primary insurances.
We do not file out-of-network or secondary insurance claims.

Medpsych Integrated is NOT in network with Medicaid.

If you have Medicare Supplemental Plan, we do not send plans to secondary insurances. You must have coordination of benefits with Medicare. If you have coordination of benefits with Medicare, your Medicare plan will "cross over" the claim to your secondary plan.
Insurance Company Name (may be different than medical)*
Subscriber ID*
Subscriber/Policy Holder Name*

First NameLast Name
Subscriber Birth Date*

MonthDayYear
Date
Relationship to Patient*
Please upload a picture of the front of your insurance card.*

Cancelof
Please upload a picture of the back of your insurance card.*

Cancelof

Practice Policies

Please thoroughly read all of our practice policies.
Financial Policy
I, Patient Name*, authorize release of any information acquired in the course of treatment necessary to complete and file medical claims to my insurance company or Medicare on my behalf. I hereby acknowledge financial responsibility for costs of services rendered for me or for the person whose account for which I am acting as guarantor. I authorize (assign) any insurance or Medicare benefits to be paid directly to Med Psych Integrated or its assignees. I am responsible for any non-covered services, supplies, co-payments or deductible at the time of service. This acceptance and assignment will be in force for all future services by all practitioners from this office.
Fee structures are subject to change based on the severity of presenting concerns, appointment length, and services provided. The providers at Medpsych Integrated have your best interest in mind and alter their scheduling to accommodate meeting your needs. Fees may be added to your account for both direct and indirect patient care for the following purposes as listed below. We value you as a patient of the practice and should you have any questions or concerns, please feel free to discuss any pricing or financial issues with the practice manager or owner.
I, Patient Name*, agree to, approve, and understand all of the following:
- Medpsych Integrated requires a valid credit or debt card for all patients.
- Upon scheduling my new patient appointment, I will provided MedPsych Integrated a valid credit or debt card. Should I not show or cancel the same day of my new patient appointment, the card will be charged $300.
- In the event of a missed follow up appointment without proper 24 hour cancellation, the card on file will be charged: $100 for missed 20 minute follow up or $150 for a 40 minute follow up.
- After your insurance processes your claim should there be a balance, the card on file will be charged for the remainder balance as it is expected that all patients maintain a zero balance.
- You have the right to request an invoice/statement at any time.
- MedPsych Integrated will not be held liable for any fraudulent charges made to the credit card account.
- If you are not the cardholder of the credit card, you agree to take full responsibility for any charges made by MedPsych Integrated to the card you have provided.
Cardholder Name*

First NameLast Name
Insurance Policy
Our providers are credentialed with several insurance providers. If we are not contracted with your insurance carrier, you are responsible for full self pay rate payment at the time of service. If you have a deductible, you are responsible for paying each visit in full at the contracted rate for your insurance carrier until you have met your deductible obligation with the carrier. If your insurance carrier requires a co-payment, this is to be paid at each visit. Please notify the office if you have a change in insurance coverage. Authorizations for your first visit are your responsibility. You are responsible for payment for services rendered regardless of any determination made by an insurance company.
- It is my responsibility to inform the office of any insurance changes.
- I agree to pay my copay or deductible at the time of service.
I,Patient Name* , direct my health care and medical services providers and payers to disclose and release my protected health information described above to my insurance.
Medication Policy
- I am responsible for my medications.
- I will not share, sell, or trade my medicine.
- I will not take anyone else’s medicine.
- I will not increase my medicine until I speak with my provider.
- My medicine may not be replaced if it is lost, stolen, or used up sooner than prescribed.
- I will keep all appointments set up by my doctor (e.g., primary care, physical therapy, mental health, substance abuse treatment, pain management)
- I will bring the pill bottles with any remaining pills of this medicine when requested by my provider.
- I agree to give a blood or urine sample, if asked, to test for drug use.
- If I break any of the rules, or if my provider decides that this medicine is hurting me more than helping me, this medicine may be stopped by my provider in a safe way.
- If I have questions, I will talk to my provider about this agreement and I understand the above rules.
Refill Policy
Refills will typically be handled during your office visit. Refills may not be given if you have not been seen in the last 3 months. Please allow 72 business hours for prescription refill requests to be processed. If you have any medication questions, please reach out to your provider through the patient portal.
- I will request refills through my pharmacy at least 3 to 5 days prior to running out of medication.
- I will request refills for controlled substances from my provider 3-5 days prior of running out of medication. I will send a request through the portal or leave a message for Medpsych Integrated to relay to my provider.
- Your provider has the right to request a random drug screen.
- If you are on a controlled substance, it is required that a UDS must be completed at least twice yearly.
- I understand that I cannot request refills early.
- I understand that if my prescriptions are lost, misplaced, or stolen they will not be refilled early.
- If I require a medication bridge, I agree to schedule and attend an appointment through the virtual (15 minute) Walk-In Clinic.
- THERE WILL BE NO REFILLS AFTER HOURS.
**YOUR PROVIDER HAS THE RIGHT TO APPROPRIATELY NOT PRESCRIBE, DISCONTINUE, OR TAPER CONTROLLED SUBSTANCES IF SUSPECTED ABUSE, INAPPROPRIATE USE, OR USE OF ILLICIT SUBSTANCES. SUBSTANCE USE DISORDER HELP IS AVAILABLE AND WILL BE OFFERED WHEN APPROPRIATE**
Controlled Substance Policy
- I will inform my provider of any current or past substance abuse, or any current or past substance abuse of any immediate member of my immediate family.
- I agree that I may be subject to establishing care with a psychologist/psychotherapist, possibly at my own expense, before any controlled substances will be prescribed to me. I agree that the need to continue routine psychotherapy visits may be revisited every three (3) to six (6) months thereafter while taking the medication.
- All controlled substances pertaining to mental health must come from a provider in the MedPsych Integrated office. My controlled substances will come from my provider, or during his or her absence, by the covering provider, unless specific written authorization is obtained from the office for an exception.
- I will inform MedPsych Integrated of any new medications or medical conditions, and of any adverse effects I experience from any of the medications that I take.
- I will inform my other health care providers that I am taking the controlled substances listed above, and of the existence of this Agreement. In the event of an emergency, I will provide the foregoing information to emergency department providers.
- I agree that my prescribing physician has permission to discuss all diagnostic and treatment details with other health care providers, pharmacists, or other professionals who provide my health care regarding my use of controlled substances for purposes of maintaining accountability.
- I will not allow anyone else to have, use, sell, or otherwise have access to these medications. The sharing of medications with anyone is absolutely forbidden and is against the law.
- I understand that controlled substances may be hazardous or lethal to a person who is not tolerant to their effects, especially a child, and that I must keep them out of reach of such people for their own safety.
- I understand that tampering with a written prescription is a felony and I will not change or tamper with my doctor’s written prescription.
- I am aware that attempting to obtain a controlled substance under false pretenses is illegal.
- I agree not to alter my medication in any way, and I will take my medication whole, and it will not be broken, chewed, crushed, injected, or snorted.
- I will take my medication as instructed and prescribed, and I will not exceed the maximum prescribed dose. Any change in dosage must be approved by a MedPsych Integrated provider.
- I understand that these drugs should not be stopped abruptly, as withdrawal syndromes may develop.
- I will cooperate with unannounced urine or serum toxicology screenings as may be requested, as well as any random pill counts of medication by the provider. Failure to comply may result in immediate discharge from the practice.
- If you are prescribed a controlled substance, a urine drug screen (UDS) is required at least twice per year in compliance with NC DEA policy.
- I understand that the presence of unauthorized and/or illegal substances in the screenings described in the paragraph above may prompt referral for assessment for a substance abuse disorder or discharge from the practice.
- I understand that medications may not be replaced if they are lost, damaged, or stolen. If any of these situations arise that cause me to request an early refill of my medication, a copy of a filed police report or a statement from me explaining the circumstances may be required before additional prescriptions are considered. If I request an early refill secondary to lost, damaged, or stolen prescriptions twice within a year, I may be discharged from the practice.
- I understand that a prescription may be given early if the provider or the patient will be out of town when the refill is due. These prescriptions will contain instructions to the pharmacist that the prescriptions(s) may not be filled prior to the appropriate date.
- If the responsible legal authorities have questions concerning my treatment, as may occur, for example, if I obtained medication at several pharmacies, all confidentiality is waived, and these authorities may be given full access to my full records of controlled substances administration.
- I will keep my scheduled appointments in order to receive medication renewals. If I need to cancel my appointment, I will do so a minimum of twenty-four (24) hours before it is scheduled.
- I understand that I may be asked to bring my medications in their original container to the MedPsych Integrated office while I am on controlled medication.
- Refills will not be given after office hours, during the weekends, and on holidays. Refill requests outside of a visit will be addressed, if appropriate, within 72hrs by the provider.
- I understand that any medical treatment is initially a trial, with the goal of treatment being to improve the quality of life and ability to function and/or work. These parameters will be assessed periodically to determine the benefits of continued therapy, and continued prescription is contingent on whether my physician believes that the medication usage benefits me. I will comply with all treatments as outlined by my provider at MedPsych Integrated.
- I have been explained the risks and potential benefits of these therapies, including, but not limited to, psychological addiction, physical dependence, withdrawal and over dosage.
- I understand that failure to adhere to these policies and/or failure to comply with physician’s treatment plan may result in cessation of therapy with controlled substance prescribing by this physician or referral for further specialty assessment, as well as possible discharge from the practice.
- I attest that the foregoing was discussed with me, and that I have read, fully understand, and agree to all of the above requirements and instructions. I affirm that I have the full right and power to sign and be bound by this agreement.
I, Patient Name*, have been informed that individuals who are prescribed certain controlled substances including, but not limited to, stimulants, benzodiazepine tranquilizers, and sedatives, can abuse those substances or may allow abuse by others, and have some risk of developing an addictive disorder or suffering a relapse of a prior addiction. Therefore, I have been informed that it is necessary to observe strict rules pertaining to their use, and I agree to follow the terms and procedures described in this Agreement as consideration for, and as a condition of, the willingness of the provider to consider prescribing or to continue prescribing controlled substances to treat my symptoms.
Telehealth Consent and Disclaimer
I understand that MedPsych Integrated offers telehealth services, enabling access to integrated psychiatric and medical care via secure video, audio, or other digital communication technologies. By agreeing to telehealth, I acknowledge the following:

Purpose and Nature of Telehealth: Telehealth allows me to receive psychiatric and/or medical consultation, diagnosis, treatment, and follow-up from a provider remotely. Telehealth sessions may include the sharing of personal health information (PHI) and visual/audio data as part of my care.

Limitations and Risks: I understand that telehealth may not be identical to in-person care and may have certain limitations, including technology interruptions, risks to data privacy, and difficulties in assessing non-verbal cues. My provider will inform me if in-person visits are recommended for any aspect of my care.

Privacy and Confidentiality: MedPsych Integrated uses secure, HIPAA-compliant communication platforms for telehealth. However, I acknowledge that complete security cannot be guaranteed. I am responsible for maintaining privacy on my end, including choosing a private, secure location for sessions.

Emergency Protocol: I understand that telehealth is not appropriate for all medical or psychiatric needs, particularly emergencies. In case of a mental health or medical crisis, I will call 911 or go to the nearest emergency room immediately. I also understand that I should inform my provider of any emergency contacts as part of my treatment plan.

Insurance Coverage and Financial Responsibility: I understand that telehealth services may or may not be covered by my health insurance plan. If my insurance plan does not cover telehealth services or if there are changes to my coverage, I agree that I am personally responsible for any unpaid claims related to telehealth sessions. I will contact my insurer to verify telehealth benefits and inform MedPsych Integrated of any changes to my coverage.

Right to Withdraw Consent: I have the right to withhold or withdraw consent to telehealth services at any time without impacting my future care, access to treatment, or benefits. If I choose to discontinue telehealth, I understand that I may need to arrange for in-person appointments.

By signing, I confirm that I have read, understand, and agree to the terms of telehealth services at MedPsych Integrated. I accept the potential risks, benefits, and financial responsibility associated with telehealth services and consent to receiving care through these means.
Additional Forms and Paperwork Policy

Such as: Short term disability (FMLA) paperwork, Emotional Support Animal (ESA) paperwork, etc.
MedPsych Integrated providers will make every effort to complete forms during your office visit if time permits; however, we cannot guarantee all forms can be completed at that time. If additional time and resources are required, a fee of $25 per hour may apply. You will be notified in advance of any charges. MedPsych also maintains a specific fee schedule for form completion. Please inquire for further details.
Cause for Termination of Care

At times, termination between a patient and provider is necessary. Termination of treatment may occur at any time and may be initiated by either the patient or the provider. Reasons for termination by the provider are generally due to:
- Violation of office policies
- Non-compliance with treatment.
- Three missed appointments (within one year) with less than 24 hours of notice or no notice at all.
If you have any questions about this, please discuss with provider. In the event that your care needs to be transferred to another psychiatric provider, MedPsych Integrated will provide assistance as able.
Authorization to Leave Messages, Receive Emails, and Receive Texts

I hereby authorize that phone messages, emails, and/or text messages are allowed to be left at the above email address/phone number(s) regarding my appointments, prescriptions, and care from Medpsych Integrated, PLLC. I understand that my electronic signature is the legal equivalent of my manual/handwritten signature on this document.
I, Patient Name*, have thoroughly read and agree to the policies of Medpsych Integrated that are detailed above.
Signature*

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Date*

MonthDayYear
Date

HIPAA FORM

Right to access your protected health information for family member, caregiver, or friend.
Would you like to add a family member, caregiver, or friend to allow them to communicate with Medpsych Integrated staff?*

YesNo
I, Patient Name*, direct my health care and medical services providers and payers to disclose and release my protected health information described below to:
Name*

First NameLast Name
Relationship to Patient: *
Please check all that apply to disclose your health information upon the request of the person named above:*

Disclose my complete health record - Including but not limited to diagnosis, lab tests, prognosis, treatment, and billing for all conditionsDisclose ONLY billing/financial informationDisclose ONLY medical information
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

	Medication	Dose	Frequency	Side Effects? YES or NO
1
2
3
4
5

	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired of having little energy
Poor appetite or overeating
Feeling bad about yourself or feeling that you are a failure or feeling you've let your family down
Trouble concentrating on things, such as reading or watching television
Moving or speaking slowly that other people have noticed or the opposite Being so fidgety or restless that you are moving around more than usual
Thoughts that you would be better off dead or thoughts of harming yourself

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

	Never	Rarely	Sometimes	Often	Very Often
How often do you make careless mistakes when you have to work on a boring or difficult project?
How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
How often do you have difficulty getting things in order when you have to do a task that requires organization?
When you have a task that requires a lot of thought, how often do you avoid or delay getting started?
How often do you misplace or have difficulty finding things at home or at work?
How often are you distracted by activity or noise around you?
How often do you have problems remembering appointments or obligations?

	Never	Rarely	Sometimes	Often	Very Often
How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?
How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
How often do you feel restless or fidgety?
How often do you have difficulty unwinding and relaxing when you have time to yourself?
How often do you feel overly active and compelled to do things, like you were driven by a motor?
How often do you find yourself talking too much when you are in social situations?
When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
How often do you have difficulty waiting your turn in situations when turn taking is required?
How often do you interrupt others when they are busy?

Welcome to Medpsych Integrated!

We want to get to know you!

Patient Health Questionnaire (PHQ-9)

Generalized Anxiety Disorder (GAD–7) Scale

Adult Self-Report Scale (ASRS) Symptom Checklist

Mood Disorder Questionnaire (MDQ)

Family History

Practice Policies

Financial Policy

Insurance Policy

Medication Policy

Refill Policy

Controlled Substance Policy

Telehealth Consent and Disclaimer

Additional Forms and Paperwork Policy

Cause for Termination of Care

Authorization to Leave Messages, Receive Emails, and Receive Texts

HIPAA FORM

Suggested zone	Score
I - Low risk	0-3: Women, 0-4: Men
II - Risky	4-12: Women, 5-14: Men
III - Harmful	13-19: Women, 15-19: Men
IV - Severe	20+: Women, 20+: Men

	Yes	No
...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
...you were so irritable that you shouted at people or started fights or arguments?
...you felt much more self-confident than usual?
...you got much less sleep than usual and found you didn’t really miss it?
...you were much more talkative or spoke much faster than usual?
...thoughts raced through your head or you couldn’t slow your mind down?
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
...you had much more energy than usual?
...you were much more active or did many more things than usual?
...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
...you were much more interested in sex than usual?
...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
...spending money got you or your family into trouble?