Check In Varinder Rathore MD Hopewell Junction

Check In Hopewell

Varinder Rathore MD
Date of Service*

MonthDayYear
Date of Visit
Patient Name*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Type of Appointment:*

OnlineIn Office
Type of Treatment: (can choose more than one)*

Psychiatric Intake (New Patient)Psychiatric FollowupSuboxone Intake (New Patient)Suboxone Followup
By selecting the service above you Acknowledge that you will perform an Oral or Urine drug screen.*

I acknowledge my mandatory oral drug screenI decline, I will let doctor know of my reasons
Would you like to update your HIPAA release? Allow authorization of your privacy to someone already not designated on your medical record.*

YesNoRemove Someone
Has any of your Personal details changed?*

Nothing ChangedEmailPhone NumberAddressInsurance PlanPrimary Care ProviderTherapistEmergency contactUpdate PharmacyAny Change in your Medical historyAll of the Above
What Details of your Medical History Changed?*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Policy Name *
Insurance Policy Number#*
Take Photo of Your Insurance Card*
Primary Care Provider*
Include phone number if available
Therapist*
Include phone number if available
Emergency Contact update:*

First NameLast Name
Relationship to Emergency Contact:*
Ex. Father, Mother, Friend, Sister, Brother, Significant Other, etc.
Emergency contact information:*
Please enter a valid phone number.
Name of Retail Pharmacy:*
Include Street Address
Pharmacy City or Zip Code:
If available or City

Payment

Private PaySuboxone Treatment

$180.00

Total

$0.00

Payment Methods

Credit Card

Apple Pay

Google Pay

Cash App Pay

HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
1. Authorization I authorize Varinder Rathore MD. PC. and Associated Providers/Clinicians (healthcare provider) to use and disclose the protected health information described below to:
Release to:*
PCP, therapist, Family member
2. Effective Period This authorization for release of information covers the period of healthcare from:*

all past, present, and future periods
3. Extent of Authorization:*

My complete medical record
4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct. 5. This authorization shall be in force and effect until ___Terminated from treatment or Discharged___, at which time this authorization expires. 6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. 7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. 8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Patient Signature*

Clear
Reason for Visit:*

No real issues, Doing well and stable on current medication regimen.May need adjustment on my medications, but overall better than last visit.I felt slight bit better but still struggling.I had some side effects from my medications and stopped taking them or would like to change medication.I feel worse since last appointment.Brought someone close to me, who understands that I am doing worse than before.I’m a new patient and struggling with issues and want help.Other issues than listed above
Do You want to Describe any Specific Details of the Issues?*
Description of issues (Be Specific)

Clinical Opiate Withdrawal Scale (Not at all)=0-1-2-3-4=(Extremely)*

	Severity
I am perspiring
My nose is running and/or my eyes are watery
I have goosebumps and/or chills
I feel nauseated or like I may need to vomit
I have stomach cramps and/or diarrhea
My muscles twitch
I feel dehydrated and/or have not had much appetite
I am having difficulty sleeping
I have a headache
My muscles and bones ache
I feel like using right now
I would rate my overall level of withdrawal

Should be Empty:

Check In Hopewell

Payment Methods

HIPAA Privacy Authorization Form