New Patient Intake Form

New Patient Intake Form

Please initial & date each page to indicate you understand these policies. Ask us questions if you don’t understand something. Thank you, and welcome!
Philosophy

Welcome to my office! I provide psychiatric assessment and treatment of adults and adolescents age 12 and older.

Please help me understand how I can help you. What are the main things you would like me to help you with? What are the things that matter most for you--and how would you like them to improve? There is room to write about this at the end of this form.

I consider the four main components in life to be the medical, psychological, social, and environmental factors. If we represented life as a chair with four legs, those four factors would each be one “leg,” providing support, balance, and helping to stabilize the chair, or life, as a whole. Weakness in one or
more legs leads to instability and causes the chair, or one’s life, to not function well.

I am committed to providing the highest quality of care for my patients, so they can control and stabilize their life. My recommendations are based on the latest medical science research, as well as over 20 years of experience working in the field. You can read more about my philosophy and practice, as well as office policies, at: harrisjensenmd.com

My approach is to work through issues while building the skills a patient needs to be happy. Primarily, my practice focuses on interpersonal skills, meditation, rational thinking skills, and/or using medication.

Together you and I will focus on building up your self-resilience by improving your insight into yourself and how best to meet your specific and unique needs.

Please take a few minutes to read, fill out, and sign the following information
Patient Name*

First NameLast Name
Guardian Name

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Social Security Number*
Sex*
Marital Status*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Home/Work/Alt Phone
Please enter a valid phone number.
Can we text you appointment reminders?*

YesNo
Email*
example@example.com
Emergency Contact*

First NameLast Name
Relation*
Emergency Contact Phone Number*
Please enter a valid phone number.
Not using insurance? Please ask for a price list for self-pay clients. Ignore any questions below regarding insurance.

Self-Pay Costs
- First Appointment 45 min- $300
- Follow-up/Med Check 30 min- $200
- Follow-up/Med Check 15 min- $100
- Medication Refill After Missing An Appointment or Not Making An Appointment On Time - $50
Are you planning on using self-pay or insurance?*

Self-payInsurance
Insurance Information

We are no longer taking Tricare, Medicaid, or Workman's comp for new patients
Primary Insurance Provider
Plan Effective Date
Member ID
Group #
Secondary Insurance Provider
Plan Effective Date
Member ID
Group #
Primary Policy Holder's Information

Leave blank if same as above
Policy Holder's Name

First NameLast Name
Relationship to patient
Sex
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Can we speak with this person about insurance questions or issues?

YesNo
If Patient is a Minor:
Guardian

First NameLast Name
Relationship
Phone
Please enter a valid phone number.
Social Security Number
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-Prescribing Pharmacy Information:
Name of Pharmacy
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Please summarize why you are seeking Dr. Jensen's assistance
Please summarize why you are seeking Dr. Jensen's assistance. What are the things that matter the most for you, and how would you like to see them change?

Credit Card Information For Credit Card On File For payments
Name On Credit Card

Type Of Credit Card (Debit or Credit, Mastercard or Visa)
Credit Card Number
Credit Card Expiration Date
Credit Card Security Code
Address Associated With Credit Card
Do You Authorize Your Credit Card Information Be Kept At This Office?
Do You Authorize This Card To Be Automatically Charged For No Shows, Late Cancellations, Copays, And Balances Due In Your Account?
The Doctor-Patient Financial Agreement

I understand that services need to be paid for at the time they are provided. I understand that I need to keep my account current in order to get further services like scheduling visits with the Dr. etc. I understand that there are no payment plans. If I am short on funds for my account, I agree to use a credit card or check or money order. I understand office services, such as getting medication refills, are only done if my account is paid up.

Paid Up/ Scheduled Up

Due to the large number of patients not keeping their appointments, or not scheduling their appointments at the agreed time, my office assistant is overwhelmed and can't get to all of her paperwork for insurance billing, etc. This is not sustainable. Therefor, patients are required to make a followup appointment, and pay up on their account, right after their visit. Almost everyone forgets to make a followup appointment if they try to remember later.

"There is a $75 charge for a refill when someone has run out of their medication because they missed making their appointment on time, or was a no show for the appointment. The refill will only be for enough medication to make it to the next appointment (not a full 30 days). And the $75 has to be paid before the refill is made. The patient can choose to not not pay that and just wait until the next visit to get a refill. The point of a medication check is to see how much medication is needed, then give enough prescriptions to make it to the next appointment. When patients don't follow through, it is viewed in the medical community as the doctor losing control of the prescribing process and letting the patient have control. Generally, this is frowned upon."

Before virtual visits (the old days) the doctor would bring the patient to the front desk, and then they would pay their bill and get scheduled, and then they would get their paper prescriptions. That prevented the chaos of many patients running out of medication after not getting to their next appointment at the agreed upon time. So we are getting back to the old way of doing things!
It is REQUIRED that the patient call their insurance provider before their first appointment and verify we are a participating provider, the patient’s specific plan benefits, co-pays, deductibles, and to understand how much the patient will ultimately be liable for. ASK FOR A “VERIFICATION OF BENEFITS STATEMENT” sent via mail or email. It outlines exactly what the insurance company agrees to pay for so there are no surprises when you are billed. If you have 2 different insurances, you need to call both insurance companies. Please make sure your Coordination of Benefits (COB) is up-to-date.

**Our office DOES NOT verify your insurance; you must do this yourself**
- Insurance Payment and Claim Rejection Process: After your appointment, our office will send a claim to your insurance company. Sending a claim doesn’t guarantee your insurance will pay. Claims are often rejected due to minor inaccuracies in address, ID numbers, misspelled names, or missing/switched numbers or letters. Please note, it is the insurance company’s choice to pay or not pay and our office has no control over them.
  - If a claim is denied, our office will try to investigate and fix the problem. However, due to the large quantity of paperwork we have, there is no guarantee the office staff will have time to investigate any specific denial. It is ultimately the patient’s responsibility to advocate for themselves and work with their insurance provider by calling the customer service number on their insurance card. Once the issue is resolved our office will re-file the claim.
- Explanation of Benefits: According to Colorado state law, insurance companies must provide an “explanation of benefits” (EOB) to both the provider and patient within 30 days of receiving a claim, whether it is rejected or not. The EOB is usually a physical letter sent to the patient’s billing address. Although now they are often available through an online portal if your insurer has one. If you don’t receive an EOB within 30-40 days of your appointment, you should call the customer service number on the back of your insurance card and request one.
Past Due Accounts
- Interest: We reserve the right to bill 1.5% finance, as provided by state law, on account balances that are 90 days or more past due.
- Collections: Accounts that are 90 days or more past due, where the patient hasn’t contacted us, or if we haven’t been able to contact the patient after numerous attempts, will be referred to a collection agency. Accounts turned over to collections will result in automatic dismissal as our patient.
- Returned Check Fee: Any returned (insufficient funds/NSF) checks will be charged $20.00 plus a $15.00 office fee or whatever the Bank Fee is plus $15.00. The minimum charge billed to your account is $35.00.
- For past due accounts, the additional applicable court and attorney fees will also be your responsibility.
I agree to these terms above:*

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Date*

MonthDayYear
Agreement to Bill Insurance

This agreement allows our office to submit charges for services to your insurance on your behalf. It also states that you are ultimately responsible for paying the bill, as well as any late fees.

I AUTHORIZE PAYMENT OF PSYCHIATRIC BENEFITS DIRECTLY TO HARRIS R. JENSEN, MD, LLC. IF MY INSURANCE DOES NOT PAY 45 DAYS AFTER THE BILL WAS SUBMITTED, THEN I UNDERSTAND I AM RESPONSIBLE FOR PAYING THAT BILL. I WILL BE REIMBURSED IF INSURANCE PAYS FOR THE SERVICES AT A LATER TIME. I UNDERSTAND I MAY BE CHARGED ADDITIONAL LATE FEES AND OFFICE CHARGES IF I DON’T PAY MY BILL WITHIN 30 DAYS.
Signing below designates that I have read, understand, and agree to the above paragraph.*

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MonthDayYear
Agreement for Additional Services

I understand that some additional services I may request from this office (missed appointment fees, phone consults, written reports, review of records, record copying, paperwork fees, authorizations required by insurance (PARs), early medication refills, etc.) may not be covered or paid for by my insurance company. I understand services will only be provided when they are paid for in advance. I can keep a positive balance in my account for this.
Signing below designates that I have read and understand the above information. *

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MonthDayYear
Late Cancellation and No-Show Policy

Appointment reminders are sent via an automated text. We do not give reminder calls. The reminder texts are 3-4 days before the appointment. Don't rely on them. If they are sent out when you are in a "dead zone" for cell service, you won't get it. Be sure you are with your phone at the time of the scheduled visit and in good cell phone coverage. If you don't receive a call at the start of your visit time, check your texts and voice mail: the doctor may have called but couldn't get through. Don't be on a call for someone else, that can cause you to not get the call from the doctor.

If you cancel with less than 48 hours notice, a no show charge will be made. You can cancel by phone or email to hjmedicalpractice@outlook.com. Don't use the form on the website for canceling visits; sometimes it has technical issues. Thank you for your understanding!
Reminders are a courtesy. It is ultimately MY (the patient's) responsibility to remember the date and time of my appointment.
Initials*
Any cancellations made with less than 48 hours’ notice will be charged a $100.00 missed appointment/late cancel fee. Timing will be counted down to the minute. 47 hours and 49 minutes is under 48 hours.
Initials*
Cancelling or no showing more than 4 times within one calendar year will lead to an evaluation by the doctor, as a transfer of services may be needed.
Initials*
Signing below designates that I have read, understand, and agree to the above paragraph.*

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MonthDayYear
Payments for Services

I understand that I am ultimately responsibility for payment for any services I receive from this office. I understand that there are services performed by this office that may not be covered by my insurance and that I am responsible for those charges.
Initials*
Name*

First NameLast Name
Email*
example@example.com
Thank you for committing to this agreement and remember, you are worth the effort!

Please let us know if you have any questions or concerns.

-Thank you,
Dr. Harris Jensen and Staff
Signature of Client or Responsible Party*

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Name*

First NameLast Name
Date*

MonthDayYear
Signature of Guardian or Co-Responsible Party

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Name

First NameLast Name
Date

MonthDayYear
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