Patient Demographics and Medication List Update 

You agree and acknowledge that email, calls, texts or any form of messaging to your home, mobile, work or other contact will pertain to information regarding things like appointments, patient portal, test results, medication side effects and prescriptions. If this information should at any time need to be modified, please complete a new Patient Demographic Form and/or ROI form with your requested change(s).

 If there are others in your household that we may communicate with, please indicate below.

Note:This does not constitute as a medical release of information and does not authorize us to share any private health information with the individuals you list below. Permissions granted by this form are limited to appointments, billing, and as a contact in the event of emergency where you cannot be reached.

If you would like your provider to speak freely about your care with another individual such as a spouse, family member, caregiver, guardian/POA or another healthcare provider, you must sign a HIPAA Release of Information. 

Please provide us your default choice of Lab company you use and which local pharmacy and mail order pharmacy you primarily use.

INSURANCE ASSIGNMENT AND SELF PAY AGREEMENT AUTHORIZATION TO RELEASE

>I certify that I have insurance coverage with the primary insurance company, if applicable; and the secondary insurance payer, if applicable, listed above. I assign directly to "Cornerstone" Psychiatric Services, Inc. (including David Donahue, D.O., David Fawks, APRN, Kristoffer Guerrero, APRN, Lenice Haber, LCSW, Nancy Stetter-Coblentz, LCSW or any clinician with the Cornerstone group), all insurance payments, if any, otherwise payable to me for services rendered. I understand I am financially responsible for deductible, co-payments, co-insurance amounts, non-covered charges, and any and all balances not covered under a contractual agreement between "Cornerstone" and my insurance or other third party payer. I authorize the use of my signature for all insurance submissions. I request that payment of authorized Medicare benefits and, if applicable, Medigap benefits, be made on my behalf to "Cornerstone" for any services furnished to me by that provider.

>If Self Pay, I understand it is my responsibility to pay for services rendered at time of visit. understand and agree that "Cornerstone" may use my health care information to the above named insurance payer(s) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. I understand that if an authorization is needed from my insurance plan, it is my responsibility to obtain such authorization and provide this to "Cornerstone". 

CONSENT FOR OFFICE POLICIES and PATIENT PORTAL POLICIES AND PROCEDURES Consent to Evaluate/Treat: I voluntarily consent that I will participate in a mental health (e.g. psychological or psychiatric) evaluation and/or treatment by a state licensed clinician at Cornerstone Psychiatric Services, Inc. This consent is knowingly and freely given. This consent will expire 7 years after my last encounter visit at Cornerstone Psychiatric. I hereby give my consent for Cornerstone Psychiatric Services and their Business Associate's (such as, but not limited to, medical billing company, EHR vendor, collection agency, automated appointment reminder vendor, dictation service, Prescription Drug Monitoring Program database, and electronic prescription vendor) to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO You can ask for a copy of the Notice of Privacy Practices provided by Cornerstone Psychiatric Services which describes such uses and disclosure in detail. I have the right to review the Notice of Privacy Practices prior to signing this consent. Cornerstone Psychiatric Services reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Privacy Officer at 1790 E Venice Ave. Ste 204, Venice, FL 34292. You can also pick up a copy in our office. With this consent, Cornerstone Psychiatric Services may communicate to me in reference to any items that assist the practice in carrying out TPO, such as, but not limited to, appointment reminders, billing statements, insurance issues and any messages pertaining to my clinical care, including laboratory test results, among others by use of phone calls to my home, mobile or other alternative location and speak or leave a message; SMS/Text message, Email, postal delivery and/or by the Patient Portal. By signing this form, I am consenting to mental health treatment; I authorize Cornerstone Psychiatric Services to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Cornerstone Psychiatric Services may decline to provide treatment to me. | understand and agree with all the preceding information unless otherwise indicated in writing. I have received or been offered to review a copy of the following documents: Cornerstone "Notice of Privacy Practices", "Office Policies", and "Patient Portal Policy and Procedures". I agree and accept the terms of all these documents. Copies of these documents are available at your request in our office or by downloading from our website, www.cornerstonepsychiatric.com.

Signature of Patient, Parent or Personal Representative:

Complete Medication List (including Over-the-Counter, Vitamins and Herbals)

Signature of Patient, Parent, Guardian or Personal Representative