houstonwesttms.com - Demographic Form

INSURANCE INFORMATION
Insurance Co. Name
Insurance Co. address
Name of Policyholder
Insurance ID #
Policyholder Date of Birth

MonthDayYear
Date
Group #
Mental Health Customer Service Phone #
Please enter a valid phone number.
AUTHORIZATION

I request and give consent to Dr. Drell to provide psychiatric services as are considered necessary or beneficial for my health and well being. My choice is voluntary and I understand that I may terminate therapy at anytime. I acknowledge that no representations, warranties or guarantees as to the results or cures have been made to me. I hereby authorize Dr. Drell or his staff to furnish information to insurance companies, utilization review companies, and EAP's concerning my evaluation/treatment. I hereby irrevocably assign to the doctor all payments for medical services rendered, unless I have paid for the services in full. I understand that I am financially responsible for all charges whether or not covered by the insurance company. I understand that in the event my account becomes delinquent, Dr. Drell may need to forward the information to a credit reporting agency or an attorney for collection assistance. I waive any rights to confidentiality with regard to information that must be divulged in resolving delinquent accounts.
Signature

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RECORDING BY PATIENTS

We respect the strict confidentiality of the physician-patient relationship. We ask the same of you. By signing below, you agree that you will not make any recording of any person in this facility without their expressed written permission.
Signature

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***PLEASE READ AND SIGN THE FOLLOWING OFFICE POLICIES****
1. We request that office charge be paid at the time services are rendered, unless other arrangements are made in advance.
2. OUR OFFICE REQUIRES A 24-HOUR PRIOR NOTIFICATION OF ALL CANCELLATIONS; OTHERWISE, THE PATIENT'S ACCOUNT WILL BE CHARGED FOR THE ENTIRE APPOINTMENT FEE, NOT JUST THE COPAYMENT. This is the accepted policy for mental health providers in the Houston area. Compliance with scheduled appointments is considered an important part of a patient's treatment. Face to face interaction is necessary to monitor the patient's progress and potential side effects of medication. When you do not keep your scheduled appointment at least 4 people are affected. You, because you don't get the prescribed treatment, another patient who could have been scheduled for the time, the physician, and the staff who have to take to take the time to return phone calls, reschedule appointments and arrange medication refills. Patients will be charged a fee, which may be more than the discounted insurance rate for appointments not cancelled with at least 24 hours notice. PLEASE NOTE: CANCELLING AN APPOINTMENT THE DAY BEFORE IS NOT ADEQUATE UNLESS IT IS AT LEAST 24 HOURS IN ADVANCE. Monday appointments can be cancelled over the weekend by leaving a message on Dr. Drell's answering machine or with his answering service. Both methods will record the date and time of the cancellation. FEE FOR THE MISSED APPOINTMENTS ARE THE RESPONSIBILITY OF THE PATIENT, NOT YOUR INSURANCE COMPANY. Payment for the missed appointment may be requested before medication refills are authorized or appointments are rescheduled. Please initial here
3. The patient will be responsible for deductibles, copayments, and any other charges the patient's insurance does not cover, including report charges, extended phone conversations, and charges for visits that were not pre-certified because the patient did not supply our office with correct insurance information prior to the visit.
4. Our office requests that the patient has all medications refilled during weekday business hours, as Dr. Drell (or the doctor on call) will not have access to the patient's medical records after business hours. Emergency refill requests may be honored, but they are subject to a $50 fee that is not covered by your insurance.
5. Patients not seen for over 3 months will need to be seen in the office before medications will be refilled. Dr. Drell needs to see you in person to review progress, side effects, update labs and adjust your medication is necessary. This is for your safety.
6. Payments for phone calls to your insurance provider or pharmacy management company for prior authorizations may be subject to a reasonable fee, usually $25. The fee is not covered by your insurance company.
7. CONTROLLED SUBSTANCE AND 90 DAY PRESCRIPTIONS: Controlled substance prescriptions or 90 day prescriptions should be obtained during office visits. If you have not been seen in the office for 30 days, there will be a nominal charge ($10-$15) to process refill requests of 90 day prescriptions or medications that require controlled substance prescriptions, such as Ritalin, Adderall, Concerta, etc. The fee is required for the physician to review your chart, document the appropriateness of the refill and write the prescription or email it through a portal determined by the DEA. Requests should be called to our office staff 3 working days in advance and picked up in a timely manner. Note that controlled substance prescriptions expire in 21 days.
8. FORMS AND LETTERS:

Patients frequently request letters for school, work, special accommodations, legal matters, etc. during or in between payments. Please keep in mind that your appointment is scheduled for the purpose of assessing your progress in treatment and response to medication. If time permits, some forms or letters may be completed in your allotted appointment time. If you have a request for a letter to be written, you may schedule time with Dr. Drell in order to compose the letter. (Continued on next page) Your fee will be determined by the length of time and level of complexity required to complete the service.

Simple (less than 5 minutes) $25.00
Moderate (10-15 minutes) $50.00
Lengthy (20-30 minutes) $100.00
Complex (30-60+ minutes) $250.00 to $350.00+/Hr

POINTS TO REMEMBER
1. It is advised to not drink alcohol of any kind while on psychiatric medications.
2. If your medication should make you drowsy, or if it slows your reaction time, do not drive or operate dangerous machinery and notify Dr. Drell. Also notify Dr. Drell, if your medication causes side effects or unexpected allergic reactions.
3. Notify Dr. Drell if there are any significant changes in your condition.
4. If you feel like you are any risk for hurting yourself or others, PLEASE NOTIFY Dr. Drell and your therapist immediately.
5. Notify Dr. Drell if you suspect or know that you are pregnant or if you plan to become pregnant in the near future, as it may affect the medications, which can safely be prescribed. Some medications (like Tegretol or Trileptal) may make oral contraceptives less effective; others may cause birth defects.
6. Some medications cause weight gain and have an increased risk of diabetes, elevated cholesterol, and triglycerides. Please understand monitoring your weight through healthy diet and exercise are necessary to take control your health and minimize unwanted medication side effects. Laboratory work may also be necessary.
7. You may want to consider self -paying for your treatment to maintain your confidentiality. We do not know what insurance companies or their employees do with the information we provide them to obtain insurance pre-certification or payment. Many patients have had difficulty obtaining new medical insurance or life insurance, if they have received a diagnosis or have been prescribed medications. (See Confidentiality Statement Form)
8. We are here to help you. Do not hesitate to call if you have any questions or concerns.
9. I have read and understand the above Office Policies and Points to Remember and had an opportunity to discuss these points and ask any questions of Dr. Drell and/or his staff.
Patient or Responsible Party's Signature

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Date

MonthDayYear
Date

NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give the Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in the Notice while it is in effect. This Notice takes effect Jan 1. 2011, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of your Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change the Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information, about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use of disclose your health information to a physician, or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide for you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by our authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in the Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patients Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity, to object to such uses or disclosures. In the even of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information,

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when were are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to a correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, e-mails, or letters).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.50 for each page after 20 pages plus $25.00 for staff time to locate and copy your health information, plus postage if you want the copies mailed to you. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure If Dr. Drell feels releasing information may be contraindicated, you can set up an appointment time to review your records with Dr. Drell to address any questions or concerns you may have.

Disclosure Accounting: You have the right to receive the list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years, but not before Jan. 1, 2011 If your request this accounting more than once in a 12- month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notices: If you receive this Notice on our Web site or by electronic mail (e-mail) , you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or your disagree with a decision we made access to your health information or in response to a request you made to amend or restrict the use or disclosure of your disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of the Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if your choose to file a complaint with us or with the U.S. Department of Health and Human Services,

Contact Officer:

William K. Drell M.D.
902 Frostwood Dr. Suite # 283
Houston, TX, 77024
Telephone: 713 464-4455
Fax: 713 464-3642

	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?

	Not at all	Several days	More than half the days	Nearly everyday
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 fidgety 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 sure	Several days	Over 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's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

NEW PATIENT INFORMATION RECORD

IF THE PATIENT IS A MINOR OR STUDENT

INSURANCE INFORMATION

*PLEASE READ AND SIGN THE FOLLOWING OFFICE POLICIES**

NOTICE OF PRIVACY PRACTICES

THE MOOD DISORDER QUESTIONNAIRE

PATIENT HEALTH QUESTIONNAIRE

Generalized Anxiety Disorder 7 (GAD-7) Scale

TMS THERAPY EXCLUSION CRITERIA

NEW PATIENT INFORMATION RECORD

IF THE PATIENT IS A MINOR OR STUDENT

INSURANCE INFORMATION

***PLEASE READ AND SIGN THE FOLLOWING OFFICE POLICIES****

NOTICE OF PRIVACY PRACTICES

THE MOOD DISORDER QUESTIONNAIRE

PATIENT HEALTH QUESTIONNAIRE

Generalized Anxiety Disorder 7 (GAD-7) Scale

TMS THERAPY EXCLUSION CRITERIA

*PLEASE READ AND SIGN THE FOLLOWING OFFICE POLICIES**