Policies & Procedures Update

Mind Spa Policies & Procedures Updated Form

Required Annually
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Marital Status
Gender (Please select gender assigned at birth)
Gender Preference (Only required if different than above)
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Reminder Preference
Employment Status
Preferred Pharmacy Name/Location
Add a photo for your patient profile (this must be an image of the patient face)
Add a picture of the Patient photo ID-this is required and must be government issued. This helps us in preventing insurance fraud. (IF patient is a minor, please upload a photo of the Responsible Party ID)
Responsible Party information (If Different from Patient) (Required for Minors)

Please disregard and move on to the next page if patient is the responsible party. In the instance that there is more than one Responsible Party please list both (i.e. mother & father)
Responsible Party Name 1

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Responsible Party Name 2

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address (if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance

If uninsured please write "Cash Pay" and move to the next page
Name of Primary Insurance
Name of Primary Insurance Subscriber

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Relationship to Patient
Policy #/ ID
Group #
Please provide photo of the Insurance Card (FRONT)
Please provide a photo of Insurance Card (BACK)
Secondary Insurance

Only required if applicable-disregard and move on to the next page if you only have one insurance
Secondary Insurance Name
Name of Subscriber

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Relationship to Patient
Policy #/ ID
Group #
Please provide a photo of Insurance Card (FRONT)
Please provide a photo of Insurance Card (BACK)

Patient Consent to Policies and Procedures
Terms and Conditions
BY SIGNING BELOW, I CERTIFY THAT I HAVE READ IN FULL, UNDERSTAND AND AGREE TO THE MIND SPA LLC POLICIES AND PROCEDURES.
Printed Name of Signee (if patient is a minor/unable to sign for themselves, please provide the name of the person legally able to sign on patient behalf)

First NameLast Name
MIND SPA REFILL REQUEST

In efforts to provide better quality of care for all of our patients, we have updated our medication refill policy.

You will need to leave a message if you have a controlled medication only. All other medications, you will need to request a refill through your pharmacy to send a request. Messages are checked throughout the day. Note: We are not open on weekends and major holidays, and on Fridays we do close early. Leave only one message as multiple messages do slow down the process. Same day requests are hard to fill due to a high volume of patients. Any delay could jeopardize your health; so we urge you to act promptly and request at least three days in advance.

Request to be filled when:

1.        You are due for a refill. Refills can only be given every 30 days.

2.        You have NOT missed an appointment. If you have missed an appointment you will need to schedule an appointment with a provider or walk-in during walk-in hours.

3.        If you are requesting a change of any kind you will need to make an appointment. Change of meds cannot be done over the phone or answered by leaving a message. Please schedule an appointment for this.

PLEASE NOTE: EVERY PATIENT IS DIFFERENT AND EACH PROVIDER HAS MADE AN INDIVIDUAL TREATMENT PLAN FOR EACH PATIENT. IT IS IMPORTANT TO COMPLY WITH THE TREATMENT PLAN YOU AND YOUR PROVIDER HAVE DISCUSSED.

Regarding the Mind Spa Payment Policy:

I understand and acknowledge the Mind Spa Payment Policy AND that I will be fully responsible for the fees not covered by my insurance. In issuance of a subpoena, regardless of who issues the subpoena, fees generated will be paid in advance.
Tobacco/Nicotine Use
Acknowledgement of Privacy Practices

Please list any names or persons with whom MIND SPA can discuss your health care information, along with the relationship to patient. If you do not wish to have anyone on a Release of Information at this time please check the appropriate box. You may always add someone at a later date. *Parents and legal guardians are not required to be on a release of information. Please ensure parents and legal guardians are on the responsible party information so our office has those names.
Check this box if you opt-out of adding anyone to a release at this time.
Name

First NameLast Name
Relationship to Patient
Name

First NameLast Name
Relationship to Patient
Name

First NameLast Name
Relationship to Patient