Evolve Physicians Patient Registration

New Patient Registration
Prior to Completing this Registration form, You must call and get approval to Register for the practice. Use the link below our names to book your appointment as well.
Evolve Psychiatry Treatment Providers *

Priyadarshan Bajpayi MD. Binu Chacko MD. Raymond Sanchez PA. Kerri Quail PA. Siji Varghese NP. Marie Neptune NP. Jean Philippe Luc NP. Andrew Kasan LMSW Ariana Lombardo LMFT. Alexandra Gleason LMFT. Lauren Jonke LMHC Janet Poretsky LCSW Paul Ammendola LCSW
Personal Information:
DateTime
Your Name: *

First Name Last Name
Date of Birth: *

Month Day Year Date Picker Icon
Phone Number *

Area Code Phone Number
E-mail *
Social Security #: *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Relationship Status: *
Employment Status: *
Primary Care Provider:
Primary Care Provider: *
Therapist / Counselor:
Therapist / Counselor: *
How were you referred to our Practice? *

Google Ad Psychology Today Vitals.com Word of Mouth Referred from PCP Yahoo Search Zoc Doc Healthgrades.com Insurance Company Referred from Therapist Website Search Bing Search Not Listed Above-Other Source
Type of Treatment Requested

Mental Health/Medication Management Suboxone (opiate outpatient detoxification) Therapy/Counseling
Which medical conditions do you have (check any that apply)? *

Hypertension High Cholesterol Arthritis Back pain COPD Cancer Obesity Epilepsy Pregnancy Dementia HIV Hepatitis Diabetes Asthma Osteoporosis Herpes Endometriosis Cirrhosis
List any Medications you currently taking even Over the counter products:
Please provide your preferred pharmacy - name, address and phone number
Do you have any Allergies to food or medications? *

Yes No
If yes, then what Allergies?
Do you have any Surgical history? *

Yes No
If yes, then what Surgeries?
Brief Psychiatric History
Do you own or have access to a firearm/gun? *

Yes No
Have you ever attempted suicide? *

Yes No
Do you currently use any illicit substances or Abuse Prescription medication(s)? *

Yes No
Which illicit substances or Abuse of Prescription medication(s) do you use?

Marijuana Opiates Crack/cocaine Methamphetamine Benzodiazepines LSD/Hallucinogens PCP Nitrous Oxide Cartridges Stimulants Heroin Cocaine Ecstasy (MDMA) Alcohol Suboxone Inhalants Glue Sniffing Cold medications (Corcicidan®)
Have you ever been psychiatrically hospitalized? *

Yes No
Name the hospital and year you were last psychiatrically hospitalized in:
Do you have any Legal issues (such as arrests, warrants, DWI, DUI, DWAI, probation or parole)? *

Yes No
List any details of your legal issues:
Upload Photo of Driver's License/ Passport or ID Card:

Upload a File

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Insurance Information:
Deductible Terms:

On the day of the appointment all deductible policies are required to pay the required amount.

Copay Terms:

All Copays are due at time of the appointment.

*We do not take any responsibilty for failed reimbursements by your insurance company.
Type of Payment *

Private Pay Insurance Plan
Name of Policy Holder: *

First Name Last Name
Insurance Plan: *
Other Policy name:
Insurance Policy #: *
Insurance Group #: *
Amount of Deductible: *
Upload Photo of Insurance Card:

Upload a File

Cancel of
Review practice policy and Acknowledge:
Emergencies

In addition to my regular office hours, my practice has coverage 24 hours a day/ 7 days a week coverage. Within a reasonable time frame, I will respond to any text, email, or voicemail. I can make time for any patient emergencies and want to be available to help you.My Hours of Preferred Call time is 9-10pm on weekdays.

Office Visit Policy

All patients will be required to present a valid insurance card (if applicable) and driver's license or photo ID, and payment will be collected at every office visit prior to being seen by the physician.

Refill Policy

Please understand I will honor all refill requests via email or telephone in 48 hours, so please be aware that you will need to call 7 days prior to your "running out" of your medication to obtain this quick response. Otherwise, the expectation is to see your provider on next or same business day in the office by scheduling an appointment to obtain a refill, and this may be by another covering physician.

Payment Policy

Payment will be requested at the time of service for all services that are non-covered or determined to be the patient's responsibility, including co- payments. Payment may be made by cash, money order, MasterCard, Visa or American Express (NO PERSONAL CHECKS). You may also pay your bill by phone. My fees are comparable to the usual and customary fees charged by other Behavioral Health physicians/practices in this area.

Insurance Claims/Billing

Evolve Psychiatry, participates with most major insurance carriers. As a courtesy to our patients, we will file insurance claims for those insurances with which we participate. Please remember, any amount not covered by insurance is ultimately the patient's responsibility. A list of the major insurance companies we participate with is on this website, but please contact your insurance company to confirm that we are still participating. We require that you bring your insurance card and photo ID to all visits. Patients with Medicaid, Managed or Third party medicaid programs or Medicare programs are not accepted to the practice. Clients with Disability or Temporary disability are also not accepted, and Private pay is also not accepted by these clients.

Cancellation Policy

Please call at least 24 hours before your office visit to cancel an appointment. If you are rescheduling an appointment, please let me know so that I can cancel it and open the time for another patient. You may be assessed a missed appointment fee of $50.00, if you cancel on the same day as your appointment, or miss an appointment completely. Also please keep in mind that 3 consecutive cancellations will be considered as noncompliance/No show equivalent and 2 or more No shows will be grounds for termination of Treatment. Once discharged or terminated from practice you will not be accepted back.
I agree the above is reviewed and also accurately reported information and by signing my name, I affirm my acknowledgement of practice policy by Evolve Psychiatry.
Signature *
Patient Consent/Contract for Treatment:
As a participant in treatment for medications and/or therapy, I freely and voluntarily agree to accept this treatment contract as follows:

1. I agree to keep and be on time to all my scheduled appointments.

2. I agree to adhere to the payment policy outlined by this office. Payments must be made via cash, credit card or certified check or cashier check. Personal checks are NOT acceptable.

3. I agree to conduct myself in a courteous manner in the doctor's office.

4. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.

5. I agree not to deal, steal, or conduct any illegal or disruptive activities in the doctor's office.

6. I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my medications are filled, that the behavior will be reported to my doctor's office and could result in my treatment being terminated without any recourse for appeal.

7. I agree that my medication/prescription can only be given to me at my regular office visits. A missed visit may result in my not being able to get my medication/prescription until the next scheduled visit.

8. I agree that the medication I receive is my responsibility and I agree to keep it in a safe, Secure place. I agree that lost medication will not be replaced regardless of why it was lost.

9. I agree not to obtain medications from any doctors, dentists, pharmacies, or other sources without telling my treating physician.

10. I will let my physician know of all medications that I am being currently prescribed including those given by other treatment providers.

11. I agree to take my medication as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor.

12. I understand that medication alone is not sufficient treatment for my condition, and I Agree to participate in counseling as discussed and agreed upon with my doctor and specified in my treatment plan.

13. I agree to abstain from alcohol, opioid, marijuana, cocaine, and other addictive substances (except nicotine).

14. I agree to provide random urine samples or testing (if requested) and have my doctor test my blood alcohol level.

15. If there is a problem and the patient cannot make the scheduled appointment please call the office and leave a message. Failure to contact the clinic and not showing up at the scheduled appointment may result in a $50.00 fee that will be assessed at the Following visit.

16. We do not take any responsibility for any failure of Insurance Reimbursements. You will be billed for any balances you are responsible for. *Suboxone treatment is a service that is unable to be reimbursed from insurance and is private pay only.

17. You must let your provider or the staff know of any changes in your insurance policy, otherwise you will be responsible for the charges incurred.

18. If you have not been compliant with your treatment visits for a period of 90 days, your case will be considered closed/inactive and be terminated from treatment of which we will send you a notification on the 90th day.

19. If you are terminated from the practice you will not be able to reschedule with our practice. You will be referred to other providers whom provide similar services.

20. I understand that violations of the above may be grounds for termination of treatment.
I agree the above is reviewed and also accurately reported information and by signing my name, I affirm my acknowledgement of Contract for Treatment by Evolve Psychiatry.
Signature *
Financial Policy Waiver/Policy:
We recommend your call your insurance company prior to rendering services from EVOLVE PHYSICIANS PC. or Any of its clinicians, to avoid such issues as not being reimbursed for your visits or to all ensure we are a covered and paneled provider under your insurance company.We are committed to providing you the best possible care. If you have medical insurance we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding.We will file your insurance claim with your primary insurance for you, however we ask that you pay any co- payment or deductible at the time services are rendered and the balance in full if your insurance has not paid in 60 days. For Insurance Co-payment we accept Cash, Money Order and all Major Credit Cards. We do not accept personal checks.We will do all we can to expedite insurance reimbursement, but you must realize that:

1. Your insurance is a contract between you, your employer and the insurance company. If we participate with your insurance plan, we are under contract to only charge what your company allows. Since each carriers "usual and customary" fees differ, we will take the appropriate discount when your insurance company pays our practice.

2. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. These non-covered services are your responsibility.We must emphasize that as Medical Care Providers; while the filing of insurance claims is a courtesy we extend to our patients, all charges are your responsibility from the date the services are rendered. We realize that temporary financial problems may affect payment of your account. If such problems arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about any of our financial policies, or any uncertainty regarding insurance coverage, please do not hesitate to ask. We are here to help you.

ASSIGNMENT OF INSURANCE BENEFITS & ACCEPTANCE OF FINANCIAL RESPONSIBILITY

I authorize the direct payment of any medical benefits to EVOLVE PHYSICIANS PC, for services rendered. I understand I am responsible for any and all usual and customary charges not paid as a result of this assignment.If the account is turned over to a third party, collection agency, or attorney, I understand a 10% service charge(Minimum of $15) will be added to the balance, and I understand I will be responsible to pay all litigation expenses, court costs, and reasonable attorney's fees.
I agree the above is reviewed and also accurately reported information and by signing my name, I affirm my acknowledgement of Financial Waiver/Policy.
Signature *
Any comments, or Further Statements:
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New Patient Registration

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