RENEWED HOPE LLC
PSYCHIATRIC CARE
RENEWED HOPE PSYCHIATRIC CARE
NEW PATIENT INTAKE AND CONSENT FORM
SECTION 1: PATIENT INFORMATION
Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Address:
SECTION 2: INSURANCE INFORMATION
Insurance Company:
Member ID:
Group Number:
Insurance Card (Front):
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Insurance Card (Back):
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Photo ID:
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SECTION 3: REASON FOR VISIT
What brings you in today?
How long have you been experiencing these symptoms?
COMMUNICATION CONSENT
I agree
SECTION 5: OFFICE POLICIES & EMERGENCY INFORMATION
This practice does not provide emergency services. In case of emergency, call 911 or go to the nearest emergency room.This practice does not provide emergency services. In case of emergency, call 911 or go to the nearest emergency room.
I understand
SECTION 6: CONSENTS
Consent for Treatment
I agree
Telehealth Consent
I agree
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HIPAA Acknowledgment
I acknowledge I have received or been offered the Notice of Privacy Practices and understand howmy information may be used.
I agree
Financial Responsibility
I agree
Medication / Treatment Risk Acknowledgment
I understand psychiatric medications have risks and benefits which will be discussed with me.
I agree
Controlled Substance / Medication Agreement
I understand:- Medications must be taken as prescribed- Lost or early refills may not be replaced- I may be subject to medication monitoring (PDMP review, drug screens if indicated)- Misuse may result in discontinuation
I agree
SECTION 7: FINAL SIGNATURE
I certify that the information provided above is accurate and complete to the best of my knowledge. I
consent to treatment.
Signature:
Date:
-
Month
-
Day
Year
Date
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