Your Journey to Hope & Wellness | Greathope Psychiatry

GREATHOPE PSYCHIATRY PLLC
Chima Asikaiwe, M. D.
310 East Interstate 30, Suite b106
Garland, Texas 75043
Tel. (469) 778-0263
PATIENT INFORMATION
Name

First NameMiddle InitialLast Name
Sex
Birthdate

MonthDayYear
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Zip Code
Home Phone
321-555-0123Format: (000) 000-0000.
Cell Phone
321-555-1234Format: (000) 000-0000.
Email address
example@example.com
Okay to leave voice mail or email?
IN CASE OF EMERGENCY
Emergency Contact:
Relationship to Patient:
Emergency Contact Number:
Do we have permission to contact them regarding your appointments, billing or in case of emergency?
THE FOLLOWING INFORMATION MUST BE COMPLETED
Who referred you?
Current Medications/Dosage/Physician
Briefly state your reason for this visit
NOTE: Payment is expected at the time services are rendered. Failure to provide us the information requested may result in a reduction or denial of payment by your insurance.
1

GREATHOPE PSYCHIATRY PLLC
Chima Asikaiwe, M. D.
310 East Interstate 30, Suite 304
Garland, Texas 75043
Tel. (469) 778-0263
PATIENT HEALTH QUESTIONNAIRE
Patient's Name:
Date:

MonthDayYear

PATIENT HEALTH QUESTIONNAIRE

Rows	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 or having little energy
Poor appetite or overeating
Feeling bad about yourself - - or that you are a failure or have let yourself or your family down.
Trouble concentrating on things, such as reading the newspaper or watching television.
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.
Thoughts that you would be better off dead or of hurting yourself in some way.

If you checked off any problem on this questionnaire so far how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?
Signature

Type your name
2

RECIPROCAL CONSENT TO EXCHANGE INFORMATION AND RECORDS
Client's Name:
Date of Birth:

MonthDayYear
I hereby consent to the release of priviledged information and records and waive the priviledge of confidentiality for medical and mental health care, alcohol and drug rehabilitation.
Signature
Name
Address
Phone
Contact NumberFormat: (000) 000-0000.
Fax
To exchange reciprocal information and records for the purpose of clarifying and enhancing my care and treatment including but not limited to:
Chima Asikaiwe, M. D. is hereby released from any and all liability arising out of, or in any way incidental to, producing records or providing information pursuant to this authorization. (A duplicate, photo static copy or facsimile reproduction of this authorization may be used in lieu of the original.) This authorization is subject to revocation in writing only by the undersigned.
Signature:
Authorized Recipient
Relationship to Client:
Date:

MonthDayYear
3

OFFICE POLICIES
Type a question
Your calls are welcomed and we will return them promptly during business hours. We do not have an after- hours answering service so you must call the office and leave a voice mail. If you need to make an appointment also please call during business hours. If you have an emergency, please call 911 or go to the nearest EmergencyRoom.
I hereby authorize Chima Asikaiwe, M. D. to provide psychiatric services to:
Who is the appointmet for?
Signature of Patient or Parent (If patient is a minor)
Date

MonthDayYear
5

GREATHOPE PSYCHIATRY PLLC
Chima Asikaiwe, M. D.
310 East Interstate 30, Suite 304
Garland, Texas 75043
(469)778-0263
AUTHORIZATION FOR THE RELEASE OF INFORMATION
(INSURANCE CARRIER)
I do hereby consent and authorize Dr. Asikaiwe to release all information contained inmy financial and medical records, including diagnoses and test results, to my insurance company or health plan, their agents and independent contractors, or any other person or entity that is responsible for paying orprocessing for payment any portion of my bill, for the purposes of administration, billing and quality and risk management. This consent applies to all records created in the course of and relating to my treatment and for the purpose of reimbursement for treatment.
I understand that I may revoke this consent at any time by giving written notice to Dr. Asikaiwe except to the extent that action has been taken in reliance thereon. If no prior notice of revocationis received, this consent will expire six (6) months after the date of patient discharge from treatment, unless another date or condition is specified.
I understand that if I refuse to consent to this Release of Information, the consequences will be that the insurance claim will not be filed.
Signature of Patient or Parent/Guardian
Date

MonthDayYear
Notice to Receiving Agency/Person
This information has been disclosed to you from records protected by Federal Confidentiality Rules (42 CFR Part 2). The Federal Rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal Rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug use patient.
6

GREATHOPE PSYCHIATRY PLLC
Chima Asikaiwe, M. D.
310 East Interstate 30, Suite 304
Garland, Texas 75043
(469)778-0263
ASSIGNMENT OF INSURANCE BENEFITS
I hereby authorize my or my child's insurance company to pay directly to Chima Asikaiwe, M. D. any insurance benefits otherwise payable to me or my child, if any by reason of the services described in the itemized statement rendered, and subject to the terms and limitations found in my insurance policy with the aforementioned company. THIS IS A DIRECT ASSIGNMENT OF RIGHTS AND BENEFITS UNDER THIS POLICY.
This payment will not exceed my indebtedness to the above mentioned assigned, and I have agreed to pay in a current manner any balance of said professional service charges over and above this insurance payment.
A photocopy of this assignment shall be considered as effective and valid as the original.
Signature of Insured or Insured Representative
Signature of Patient
Date

MonthDayYear
7

GREATHOPE PSYCHIATRY PLLC
Chima Asikaiwe, M. D.
310 East Interstate 30, Suite B106
Garland, Texas 75043
(469)778-0263
ACKNOWLEDGEMENT OF RIGHTS AND RESPONSIBILITIES
- YOUR RIGHTS
- To be treated with dignity and addressed in a respectful manner.
  Consistent, quality care by qualified and trained professionals in a clean and safe setting.
- Humane care and treatment free of abuse, neglect, humiliation, threats or exploitation.
- Privacy of your treatment and your records.
- To be informed of risk, benefits and alternatives to medications and/or therapy.
- To consult with another licensed practitioner at your own expense.
- To make a complaint or grievance.
- The same legal rights and responsibilities as all citizens, unless otherwise indicated by law.
- The right to be free from discrimination due to race, color, religion, national origin, gender, disability, sexual orientation or marital status.
  
  YOUR RESPONSIBILITIES:
- Please notify your provider immediately of any concerns, questions or feedback you may have regarding your sessions and your care.
- Keep appointments and when unable to do so for any reason, notify your counselor or physician's office with at least 24 hours' notice prior to your appointment. You will be charged $75.00 for appointment cancellations without 24-hour notice.
- To pay a fee of $15.00 for any medications if required on the same day.
- To pay a fee of $30.00 for treatment reports you request on your behalf and/or for copies of your records.
- All co-pays, fees or charges will be collected at the time of service. There is a $30.00 fee for all returned checks.
- To maintain a clean and safe office environment — avoid bringing any food or drinks into the clinic.
- To maintain safe settings by not bringing weapons, non-prescribed drugs or alcohol on the premises of the clinic.
- Treat your provider, office staff and furnishings with respect and follow all posted office rules.
- Provide accurate and complete information about current problems, past illnesses and treatments and other pertinent information.
- Inform us if you are receiving counseling, medications or other therapeutic services from another clinician.
- Participate in treatment decisions and follow the agreed upon plan or recommendations.
- Check with your counselor or physician's office about your appointment if inclement weather is forecasted.
- You may be referred to another provider for failing to follow these responsibilities.
- Maintain supervision and responsibility for your children and family while in the office.
- Pay for any damages caused by the careless, reckless or intentional behavior of you or your family.

Acknowledgement of Rights & Responsibilities
Name

First NameLast Name
Date

MonthDayYear
Signature of Patient

GREATHOPE PSYCHIATRY PLLC
Chima Asikaiwe, M. D.
310 East Interstate 30, Suite B106
Garland, Texas 75043
(469)778-0263
PATIENT NARCODIC & ADHD MEDICATION
Name

First NameLast Name
Check all boxes
Signature
Date

MonthDayYear
Should be Empty:

GREATHOPE PSYCHIATRY PLLC

PATIENT INFORMATION

IN CASE OF EMERGENCY

THE FOLLOWING INFORMATION MUST BE COMPLETED

GREATHOPE PSYCHIATRY PLLC

PATIENT HEALTH QUESTIONNAIRE

RECIPROCAL CONSENT TO EXCHANGE INFORMATION AND RECORDS

OFFICE POLICIES

GREATHOPE PSYCHIATRY PLLC

AUTHORIZATION FOR THE RELEASE OF INFORMATION

Notice to Receiving Agency/Person

GREATHOPE PSYCHIATRY PLLC

ASSIGNMENT OF INSURANCE BENEFITS

GREATHOPE PSYCHIATRY PLLC

ACKNOWLEDGEMENT OF RIGHTS AND RESPONSIBILITIES

Acknowledgement of Rights & Responsibilities

GREATHOPE PSYCHIATRY PLLC

PATIENT NARCODIC & ADHD MEDICATION