PATIENT INFORMATION FORM
Patient Name (please print):______DOB:______Sex (M/F): ______
Service Requested:_____Medication Management _____ Psychotherapy
PATIENT DEMOGRAPHIC INFORMATION
Street Address/Zip:
Marital Status: / Email:
Main Phone#: / Other Phone#:
Primary Insurance: / ID #:
Policyholder’s Name: / Policyholder’s DOB:
Secondary Insurance: / ID#
Policyholder’s Name: / Policyholder’s DOB:
EMERGENCY CONTACT INFORMATION
Relationship: / Daytime Phone #:
Evening Phone #:
Cell Phone #:
Name:
Address:
City, State, ZIP:
MEDICAL HISTORY
Are you currently taking any supplements or over-the-counter medications (herbs or vitamins)? □ YES □ NO
If yes, please describe: ______
Do you smoke cigarettes or tobacco products? □ YES □ NO(if “yes,” how much and for how long) ______
Did you smoke cigarettes or use tobacco products in the past? □ YES □ NO(if “yes,” how much and for how long) ______
Do you drink coffee of caffeinated beverages? □ YES □ NO(if “yes” which and how much) ______
Do you drink alcohol? □ YES □ NO(if “yes,” how much and how often) ______
Drug use? (Marijuana, Cocaine, Pain Pills, etc.) Please list: ______
Are you allergic to or have you ever had an adverse reaction to any food, medication, or other substances? □ YES □ NO
Please list all known allergies or sensitivities: ______
Are you currently taking any prescription medication(s)? □ YES □ NO (if “yes” please list below)
Medication Name Dosage Date Prescribed Reason Prescribed Prescribed By Tolerance/Adverse Reactions
Have you ever had any emotional or substance abuse treatment or psychiatric hospitalization? □ YES □ NO (if “yes” please describe below)
Treatment Date(s) Facility Reason for Treatment Duration Outcome and Follow-Up Care
Do you have any other medical conditions (Diabetes, Heart problems, etc.)? □ YES □ NO (if “yes” please describe below)
Past Current Medical Condition/Diagnosis Diagnosed When? Medication Prescribed Results
□ / □□ / □
□ / □
□ / □
Have you ever had any surgeries or medical hospitalization(s)? □ YES □ NO (if “yes” please describe below)
Surgery/Hospitalization Date Reason for Treatment Outcome and Follow-Up Care
Primary Care Physician: ______Phone Number: ______
Presenting Complaint (Describe, in detail, what is bothering you, when started, treatments, tests performed, severity, and other symptoms):
______
Past Psychiatric History (Please Elaborate) ______
______
Family Psychiatric History (Please be specific):
______
Family History:
. Alive/Deceased Age Health Problems/Cause of Death
FatherMother
Brothers/Sisters
Brothers/Sisters
Pleaseindicateany symptoms/problems you currently have:
___General Recent change in appetite, weight gain, or weight loss. Fevers, chills, or sweats.
___Head Occasional mild headaches, migraines, recent trauma or concussion
___Eyes Recent visual changes or double visional. Presbyopia (need bifocals), Cataracts, or Glaucoma
___Ears Ringing, Infection, drainage, or pain. Mild Hearing Loss, Hearing Impaired, or use hearing aid
___Nose/Throat Frequent nose bleeds, bleeding gums, sores in mouth or lips, difficulty swallowing, or hoarseness.
___Lungs Wheezing, chronic cough, emphysema, or COPD, coughing up blood. TB or positive skin test, sleep apnea,
CPAP use, Pulmonary Embolism, or Asthma
___Heart Chest pain or angina, heart skips, rapid heart rate, shortness of breath, Heart attack, Atrial fibrillation
Pacemaker, Mitral valve prolapse, Hypertension
___Breast Current breast mass, nipple discharge, personal history of breast cancer, Breast Augmentation, Current
abnormal mammogram or sonogram, Last mammogram ______(month and year),
___Digestive Abdominal pain, nausea, vomiting, bloating, heartburn, or GERD, diarrhea, constipation, Cirrhosis, jaundice,
Gallstones, Black stools, blood in stool, hemorrhoid problems, History of cancer, Crohn’s disease ulcerative
colitis, diverticulitis, or irritable bowel disease
___Genito-urinary Difficulty urinating or holding urine, frequent urination at night, Blood in urine, kidney stones, herpes
MEN: discharge from penis
WOMEN: Date of Last Menstrual Period: ______, Menopause (age ____),Hysterectomy (age _____).
___Musculoskeletal Pain in joints, pain in muscles, muscle weakness, fibromyalgia, arthritis under treatment, Chronic back
problems, swollen ankles, varicose veins
___Neurological Dizziness, loss of consciousness, transient loss of function, stroke, seizures
___Skin Rash, psoriasis, non-healing lesions, history of skin cancers or melanoma
___Endocrine Thyroid disorder, masses, heat or cold intolerance, or taking thyroid medication, Diabetes under
treatment, excessive thirst, hunger, or urination. Adrenal or pituitary disorder.
___Hematologic Anemia, bruise easily, excessive bleeding, swollen glands, leukemia, lymphoma, transfusions, Blood
clots, phlebitis, deep venous thrombosis, anticoagulated with Coumadin, sickle cell
___Infections HIV positive, history of hepatitis (type ______), staph infections, MRSA, or ORSA
CONSENT AND AUTHORIZATIONSCONSENT TO TREAT: I hereby consent to examination and treatment by my health care provider at the office of Chirag V Desai, M.D., LLC (Desai Health). I understand that my healthcare provider may access medical information about my medication use from electronic prescribing software and databases. I hereby affirm that I am of legal age and otherwise competent to consent to medical treatment. If not, the person signing below represents that such person as the parent, legal guardian or person otherwise allowed by law to consent to the examination and treatment of the patient and by their signature hereto consents.
AUTHORIZATION AND ASSIGNMENT OF BENEFITS: I hereby authorize the office of Chirag V Desai, M.D., LLC (Desai Health) to bill my insurance for services rendered and to release any information that may be required to secure payment for charges incurred by me or on my behalf. I authorize payment directly to my provider of any insurance benefits otherwise payable to me and in the event I receive payment from my insurance carrier, I agree to endorse any payment I receive over to the office of Chirag V. Desai, M.D. I also authorize the release of any information to county, state, or federal public health agencies, as required by law.
Patient’s Signature (Responsible Party if Minor): ______Date: ______
NOTICE OF PRIVACY PRACTICES
You may request a copy of the Privacy Practice Form as required by HIPPA at any time during your treatment, or from
ADMINISTRATIVE AND FINANCIAL AGREEMENTWe feel that all patients deserve the best behavioral health care that we can provide. Your understanding of our Financial Policy is important to our
professional relationship and we feel that everyone benefits when clear financial policies are outlined and agreed upon.We will make every effort to
assist you with your insurance company to make sure your treatment is authorized and reimbursement is received.
Our professional services are rendered to you, not the insurance company. Therefore, payment for services is ultimately your responsibility.
I realize that if my insurance company fails to pay my balance in full, it is my responsibility to pay for services rendered.
I further understand that such payment is not contingent on any settlement, judgment, or insurance payment by which I may recover said fee(s).
Iunderstand and agree that if I fail to make timely payments on my account, as agreed upon by my healthcare provider, my account will
be turned over to a collection agency for handling and I will be responsible for all associated costs.
I understand that there will be a $50 fee for all returned checks. Returned checks are not deposited twice, and if not paid, may be turned over to the
State Attorney’s office for handling.
Patient’s Signature (Responsible Party if Minor):______Date:______
MEDICAL RECORDS/FORMS FEES
Medical records may be requested and sent, if approved. Our fees are compliant with the Florida Statutes and are $1 per page up to 25 pages,
and $0.25 cents per page thereafter. Patient is responsible for fees if not paid by requesting party within 60 days. In the event you need a letter
or forms completed, there will be a fee for these services. The fees vary and we will notify you of the exact cost depending on your specific needs.
Patient’s Signature (Responsible Party if Minor):______Date:______
*OFFICE POLICIES*
In order to facilitate your care, we have developed certain policies and procedures that we feel are important in establishing a working partnership. Please read these policies carefully; Your signature on the last page acknowledges your understanding of these policies and is required for treatment to commence. Thank you.
APPOINTMENTS
1. You are expected to arrive for your appointment 10-15 minutes early to complete the check-in process, and address any issues, prior to being seen. As a courtesy to our patients, we offer an appointment reminder service. However, if for any reason, our office fails to call you, you are still responsible for keeping the appointment. Failure to do so will result in no-show or late cancellation fees (see Fees for Services).
2. Please provide 24-hours’ notice to CANCEL appointments to avoid a late cancellation fee (see Fees for Services for additional information). Note: Due to excessive weekend cancellations, a late cancellation fee will now be charged for any Monday cancellation not done so BEFORE NOON on Friday prior to the weekend. If you have a Tuesday appointment, after a 3-day weekend that resulted from an observed U.S. Federal Holiday, cancellations must be made BEFORE NOON the Friday prior to the weekend.
3. Cancellations will be accepted by office staff via telephone, or voicemail, to the office phone number only. Requests for cancellations sent via email, text message, cell phone, etc. will not be acknowledged and a No-Show fee will be charged (see Fees for Services for additional information). All No-Show and late cancellation fees must be paid prior to your next scheduled visit.
BILLING AND INSURANCE
1. Insurance companies pay per amount of face-to-face time the provider spends with a patient. If you are late for your appointment/session, we are not able to bill your insurance for time set aside for your visit. To recoup the lost revenue, you will be charged a late fee equal to the differenceof the reimbursement amounts for your original appointment and the billed appointment. If you arrive too late for your appointment, you may not be seen and will have to reschedule.
2. Self-pay patients will be billed per amount of time scheduled. In case of late arrival and/or a request to reschedule, you will still be billed for the full amount of time originally scheduled.
3. Our office must be notified of any insurance changes PRIOR to your next appointment so that we can verify eligibility and benefits. If you do not inform us of changes, you will be responsible for any charges not coveredby your insurance company. All payments for co-pays, deductibles, co-insurance, and non-covered services are payable at the time service is rendered. You will be billed for any applicable balances.
PRESCRIPTIONS AND MEDICATIONS
1. Refill requests require three (3) business days to process. Please keep track of your medication refill needs appropriately. Refills are NOT processed on weekends or holidays. There is NO guarantee that urgent demands for refills will be met within this three-day window. We do not accept refill requests from pharmacies, and all such requests will not be acknowledged. PLEASE ASK YOUR PHARMACY TO TAKE YOUR PRESCRIPTIONS OFF THEIR AUTO-REFILL SYSTEM.
2. You should receive enough medication/refills to last in between appointments. If you require refills, due to missed appointments or lost prescriptions, a fee will be charged (see Fees For Services). Medications may not be prescribed if you have not been seen in over FOUR months. You may need to be seen for re-assessment before medications can be prescribed.
3. Your provider may choose NOT to prescribe Benzodiazepines (i.e., Xanax, Valium, Ativan, etc).Providers at Desai Health DO NOT prescribe narcotic pain medications (i.e., Oxycontin, etc). Patients who misuse, overuse, or abuse any medications will be discharged from the practice.
4. If you are receiving medications from a Patient Assistance Program it is your responsibility to call the office at least one month prior to running out of your medication and ask us to order refills.
TREATMENT AND CONTINUITY OF CARE
1. To ensure adequate medical oversight and practice in accordance with the accepted standards of care, I agree to be seen for all follow-up appointments at least every three to four months. I understand that noncompliance with my provider’s treatment recommendations, or laboratory monitoring while taking medications, will result in discharge from the practice.
2. If you have not been seen in six (6) months or more, your chart will be closed and you will be discharged from the practice. A return to care would be at the discretion of, and upon approval from, the rendering provider.
3. If two appointments in a row are missed, without explanation, any remaining scheduled/standing appointments will be cancelled and you may be discharge from the practice.
4. A parent or guardian MUST be present at the time of any minor child’s appointment. Medication changes cannot be made without parental consent.
FEES FOR MEDICATION MANAGEMENT SERVICES
New Patient Evaluation*:MD - $300ARNP - $250
Follow-up visit*:MD - $140ARNP - $120
Extended follow-up visit*:MD - $220ARNP - $190
No Show and Late Cancellation Fees are equal to the fee for the scheduled appointment time as indicated above and must be paid prior to your next appointment.
Phone consultation, MD: $65 per 10-minute intervalduring office hours, or per 5-minute interval after hours
Phone consultation, ARNP: $55 per 10-minute intervalduring office hours, or per 5-minute interval after hours
Refills requiring same-day completion, OR lost prescriptions - $50 each; Refills requiring next-day completion - $25 each
FEES FOR PSYCHOTHERAPY SERVICES *
New Patient Evaluation* - $200
45-minute session* - $100;
Extended sessions* - $50 per each additional 20-minute increment
No Show and Late Cancellation Fees are equal to the fee for the scheduled appointment time as indicated above and must be paid prior to your next appointment.
Phone consultation during office hours - $25 per ten-minute interval (or any portion thereof); Phone consultation after office hours - $25 per five-minute interval (or any portion thereof)
*The visit and session fees will apply if you are self-pay (i.e., you do not have insurance or we are not contracted with your insurance plan). Fees may also apply if your insurance does not cover these services for any reason.
OTHER OFFICE SERVICES
Letters/Documents and completion of forms - $25 and up (according to complexity and time spent). Fees must be paid prior to release of completed documentation. All forms and letters require 7-10 business days for completion. The fee will be doubled for any request needed sooner than 7 business days from the date of the request. All fees must be paid, or payment arrangements made with our office, prior to your next visit or scheduling of your next appointment.
MESSAGES, EMERGENCIES, AND AFTER-HOURS CALLS
1. In case of emergency call 911 or go to the nearest emergency room. Our office is NOT equipped to handle any type of emergency. DO NOT come to our office if you feel the situation is dire.
2. If you have non-emergent concerns after hours, you can leave a message that will be checked the next business day. In general, if there is an emergency, you will be told to go to the ER or call 911.
3. Messages are checked every couple of hours, on workdays, when the office is open; you will have advance notice, if possible, of office closures. Calls are returned according to clinical acuity.
4. If any provider returns a call to you from their personal cell phones, and you are able to obtain the phone number, DO NOT use that number for any reason. We ask that you always contact the office with appointment and refill requests or clinical concerns. Do not text, email, or leave messages on any provider’s personal cell phone, or email, as those messages will not be acknowledged.
5. None of the providers at Desai Health are associated with, or have admitting privileges, to any hospital. We do, however, try to collaborate with hospital staff if you are admitted for psychiatric treatment. Keep in mind: we must be notified of your admission to participate in care coordination. If a psychiatric hospitalization occurs, please notify our office – do not rely on hospital staff to contact us.
I hereby attest that I have read and understand the information provided to me regarding the Office Policies, and I agree to abide by these terms and conditions. I understand that if the above policies are not adhered to, the providers at Desai Health will not be able to provide my care and I may be discharged from the practice.
______
SignatureDate
______
Printed Name
DESAI HEALTH
CREDIT CARD AUTHORIZATION FORM
Name of Patient: ______DOB: ______
Credit Card Type: ___VISA ___MASTERCARD ___AMERICAN EXPRESS ___ DISCOVER
Credit Card Number: ______
Expiration Date: ______CVV: ______
Name as it appears on the card: ______
Billing Address for Credit Card:
Street: ______
City, State: ______
Zip Code: ______
Phone Number: ______
I authorize Chirag Desai, MD, LLC (dba Desai Health) to charge this credit/debit/HSA card for any and all copays, deductibles, co-insurance, patient responsibility portions of my insurance (if applicable), fees for the completion of forms and/or letters, prescription refills, lost prescriptions, and missed/no show or late appointment fees.
I certify that I am an authorized signer on this card and that the card number and signature below are the same as those on file with the issuer of the card.
Cardholder Signature: ______Date: ______
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