7400 E. Pinnacle Peak Road Suite: 206

Dr. Saif Jaffery, MD

7400 E. Pinnacle Peak Road Suite: 206

Scottsdale, AZ 85255

Checklist (Insurance)

1. Patient Treatment Contract (2 pages)

1. Addiction Consent Form

1. AUDIT

1. Patient Intake Social/Family History

1. Patient Intake Medical History (4 pages)

1. Office Policies (With Insurance)

1. Patient Info (With Insurance)

Patient Treatment Contract - Addiction

Patient Name______Date: ______

As a participant in the addiction program at Scottsdale Behavioral Health “SBH” I agree to total sobriety, 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

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 medications to another person. I understand that such mishandling of my medication is a serious violation of the agreement and would result in my treatment being terminated without 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 buprenorphine is 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 understand the frequency of visits is decided by my doctor, based on my medical needs, and I agree to abide by the doctors recommendations in this regard.

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

9. I agree that the medication I receive is my responsibility and I agree to keep it in a safe place. I agree that lost medication will not be replaced regardless of why it’s lost.

10. I agree not to obtain controlled medications from any doctor’s, pharmacies, or other sources without telling my treating physician at Scottsdale Behavioral Health.

11. I understand that mixing buprenorphine, with other medications, especially benzodiazepines (for example, valium, klonopin, or xanax), can be dangerous, I also recognized that several deaths have occurred among persons mixing buprenorphine and benzodiazepines (especially if taken outside the care of a physician, using routes of administration other than sublingual or in a higher than recommended therapeutic doses).

12. 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.

13. 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.

14. I agree to abstain from alcohol, opioids, marijuana, cocaine, and other addictive substances (excepting nicotine).

15. I agree to provide random urine samples or go to labs for drug testing, and allow my doctor to test my alcohol level.

16. I agree and understand that I need to have a primary care physician with regular follow ups to assure my general physical health and routine blood work up including blood count/ metabolic profile/LFT, or other blood work up.

17. I agree and consent to release substance abuse history including but not limited to my diagnosis, medications, treatment, compliance, complications and other related medical information to pharmacy, and Primary Care Physician if need arises. SBH strongly believes it’s important to have family involvement in your recovery. You will be asked to sign a release of information to have open communication between your treatment team and family.

18. Counseling is an important part of your recovery. Once you are enrolled at the group counseling at SBH you are expected to follow through with the group rules. If you are dropped from the counseling program for any reason you may also no longer be in the doctor’s care.

19. I understand that the doctor may choose to check the controlled medications I am prescribed by other physicians at website. The Information obtained from the website can be used for treatment decisions.

20. I understand the treatment I receive at SBH is exclusively for Addictive Disorders and I will pursue additional mental health care by a different medical provider/doctor if other mental health conditions co-exist as decided by your doctor.

21. I understand that violations of the above may be grounds for termination of treatment.

______Date: ______

Patient Signature:

Addiction Consent Form

Patient Name: ______Date: ______

I, ______voluntarily authorize SBH to conduct an evaluation and treatment of my addictive disorders. I acknowledge that after first visit and any time during my treatment there might be medical reasons where I no longer meet criteria for outpatient treatment, due to complicated withdrawals or other medical/clinical/ethical factor. This can be a reason for a referral to a higher level of care or other facilities.

Patient Signature: ______Date: ______

Physician Signature: ______Date: ______

AUDIT

Patient Name: ______Date: ______

1.How often do you have a drink containing alcohol?

(0) Never (1) Monthly or less (2) Two to four times a month

(3) Two to three times a week (4) Four or more times a week

2.How many drinks containing alcohol do you have on a typical day when you are drinking? [Code number of standard drinks.]

(0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7 to 9 (4) 10 or more

3.How often do you have six or more drinks on one occasion?

(0) Never(1) Less than a monthly (2) Monthly(3) Weekly

(4) Daily or almost daily

4.How often during the last year have you found that you were not able to stop drinking once you have started?

(0) Never(1) Less than monthly (2) Monthly (3) Weekly

(4) Daily or almost daily

5.How often during the last year have you failed to do what was normally expected from you because or drinking?

(0) Never(1) Less than daily(2) Monthly (3) Weekly

(4) Daily or almost daily

6.How often during the last year have you needed to first drink in the morning to get yourself going after a heavy drinking session?

(0) Never(1) Less than monthly(2) Monthly(3) Weekly

(4) Daily or almost daily

7.How often during the last year have you had a bad feeling of guilt or remorse after drinking?

(0) Never(1) Less than monthly(2) Monthly(3) Weekly

(4) Daily or almost daily

8.How often during the last year have you been unable to remember what happened the night before because you had been drinking?

(0) Never(1) Less than monthly(2) Monthly(3) Weekly

(4) Daily or almostdaily

9.Have you or someone else been injured as a result of your drinking?

(0) No(2) Yes, but not in the last year(4) Yes, during the last year

10.Has a relative or friend or a doctor or other health worker been concerned about your drinking or suggestedyou cut down?

(0) No(2) Yes, but not in the last year(4) Yes, during the last year

Scoring: A score of 8 or more indicates strong likelihood of harmful alcohol consumption.

PATIENT INTAKE: Social/Family History

(To be completed by patient)

PatientName ______Date: ______

(Circle one) Married Single Long-term relationship Divorced/Separated

Years married/in long-term relationship ______Times Married ______Times Divorced ______

Children? ( ) N ( ) Y Current ages (list) ______

Residing with you? ( ) N ( ) Y If no, where? ______

Where are you currently living? ______

Do you have family nearby? ( ) N ( ) Y (Please describe) ______

Education (check most recent degree):

( ) Graduate school ( ) College ( ) Professional or Vocational School

( ) High School Grade ______

Are you currently employed? ( ) N ( ) Y Where (if “no, ” where were you last employed?) ______What type of work do/did you do? ______How long have/did you work (ed) there? _____

Have you ever been arrested or convicted? ( ) N ( ) Y

( ) DWI ( ) Drug-related ( ) Domestic violence ( ) Other

Have you ever been abused: ( ) N ( ) Y

( ) Physically ( ) Sexually (including rape or attempted rape) ( ) Verbally ( ) Emotionally

Have you ever attended:

AA ( ) Current ( ) Past NA ( ) Current ( ) Past CA ( ) Current ( ) Past

ACOA ( ) Current ( ) Past OA ( ) Current ( )Past

If you are not currently attending meetings, what factors led you to stop?

______

Have you ever been in counseling or therapy? ( ) N (Please describe)

______

Patient Intake: Medical History

(To be completed by patient)

Use the opposite side of the page as necessary to complete your answers. Please print legibly.

Name: ______

Address: ______

Phone (w) ______(h) ______(c) ______

DOB: ______Age: ______SS# ______

Emergency Contact: ______

Relationship to patient ______Phone ______

Primary care physician ______Phone ______

Date of last physical ______Have you ever had an EKG? ( ) N Date ______

Current or past medical conditions (check all that apply)

( ) Asthma/respiratory / ( ) Cardiovascular (heart attack, high cholesterol, angina)
( ) Hypertension / ( ) Epilepsy or seizure disorder / ( ) GI disease
( ) Head trauma / ( ) HIV/AIDS / ( ) Diabetes
( ) Liver problems / ( ) Pancreatic problems / ( ) Thyroid disease
( ) STDs / ( ) Abnormal Pap smear / ( ) Nutritional deficiency

Other (Please describe) ______

______

If there a family history of any of the illnesses listed above, please put an “F” next to that illness

MD NOTES: ______

______

______.

Is there a family history of anything NOT listed here? (Please explain) ______

______

______.

MD NOTES: ____________

______

______.

Have you ever had surgery or been hospitalized? (Please describe)

____________

______

______.

MD NOTES: ____________

______

______.

Childhood Illnesses

Measles / ( ) N / ( ) Y / Mumps / ( ) N / ( ) Y / Chicken Pox / ( ) N / ( ) Y

Have you or a family member ever been diagnosed with a psychiatric or mental illness? (Please describe) ____________

______

______.

Have you ever taken or been prescribed antidepressants? ( ) N For what reason ______

Medication(s) and dates of use: ______Why stopped: ______

Please list all current prescription medications and how often you take them (example: Dilantin 3x/day).

DO NOT include medications you may be currently misusing (that information is needed later)

____________

______.

Please list all current herbal medicines, vitamin supplements, etc. and how often you take them ______

______.

MD NOTES____________

______

Please list any allergies you have (penicillin, bees, peanuts) ______

MD NOTES ______

Tobacco History

Cigarettes: Now? / ( ) N / ( ) Y / In the past? / ( ) N / ( ) Y
How many per day on average? ______/ For how many years? ______
Pipe: Now? / ( ) N / ( ) Y / In the past? / ( ) N / ( ) Y
How often per day on average? ______/ For how many years? ______

Have you ever been treated for substance misuse? ( ) N (Please describe when, where and for how long) ______

How long have you been using substances?

Substance Use History

No / Yes/Past
or
Yes/Now / Route / How Much / How Often / Date/Time
of Last Use / Quantity
Last Used
Alcohol
Caffeine (pills or beverages)
Cocaine
Crystal Meth- Amphetamine
Heroin
Inhalants
LSD or Hallucinogens
Marijuana
Methadone
Pain Killers
PCP
Stimulants (pills)
Tranquilizers/sleeping pills
Ecstasy
Other

Did you ever stop using any of the above because of dependence? ( ) N (Please list) ______.

What was your longest period of abstinence?

______.

MD NOTES: ______.

OFFICE POLICIES

Addictive Disorders

Scottsdale Behavioral Health (SBH) is dedicated to providing Addiction services, following basic medical code of ethics, and treating patients with dignity and respect. Below are our office policies and conditions of care.

Policy for Release of Information: SBH will treat all client contacts and records in a confidential manner. In the interest of quality of care, SBH may disclose all or part of the patients’ medical, psychological and/or financial records to the following third parties as necessary.

• Any party associated with payment of all or part of the financial obligation including insurance companies, workers compensation payers, governmental agencies, billing service personnel, or electric billing intermediaries.
• Any professional member of SBH including psychiatrists, psychologists, social workers and/or therapists at the discretion of the treating clinician.
• Primary care physicians and other health care professionals in order to provide continuity of care.

Emergency calls Policy: During business hours and after hours emergencies must call 911 or go to the nearest emergency room. For any other reasons clients can leave a message in the provider’s mailbox or follow the voice message instructions to contact the provider.

Billing Policy: SBH will bill your insurance as courtesy, if indicated by the patient. The responsible party agrees to provide all insurance information, at or prior to the first appointment. The responsible party agrees to notify the office of changes in coverage within 10 days and is responsible for all charges not covered by insurance as allowed by third party payor agreement.

Co-payments, Coinsurance, and any deductibles are due at the time of service. Any check which is received back from the bank is subject to a $25.00 Processing Fee.______( Please Initial)

Phone calls, written reports, correspondence legal and disability paper work is subjected to an additional charge.______(Please initial)

There will be a $10.00 charge for all records to be copied that will include the first five pages any additional pages will be 10c per page.

Please be aware that “Scottsdale Behav” will appear on your caller ID whenever we call the number you provided.

Appointment cancellation Policy: Please contact the office at least 24 hours in advance to cancel an appointment. The insurance does not cover missed appointments and late cancellations. Therefore, the responsible party will be billed for 100% of the charge. ______(Please Initial)

Privacy Policy Notice: I acknowledge that I have received a copy of the Arizona Privacy Notice

______(Please Initial)

I hereby authorize SBH to conduct an evaluation and perform treatment for myself and/or my dependents with regard to Addiction services only.

Signature: ______Date:______

Patient Information

Name: ______DOB: ______

Address: ______

City______State______Zip Code______

Home Phone______Cell Phone______

Marital Status ______

Employed Full-Time StudentHighest level of school______

Sex (M/F) ______Social Security Number ______

Who is responsible for this account? ______

Relation to patient? ______

If child:Father’s Name ______Work Phone ______

Mother’s Name ______Work Phone ______

Referral Source: ______

Primary Care Physician______Phone ______

In case of emergency please notify: Name: ______Phone: ______

Employer Information:(Father and Mother if minor)

Responsible Party:Employer Name______

Employer Address______

Spouse/ Guardian:Employer Name______

Employer Address______

Insurance Information:

Primary Insurance Company Name______

Social Security Number of Policy holder______

Name of Policy Holder______DOB______

Policy Number______Group Number______

PATIENT’S OR AUTHORIZED PAERSON’S SIGNATURE: I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.
SIGNED: DATE: / INSURED’S OR AUTHORIZED PERSON’S SIGNATURE: I authorize payment of medical benefits to the undersigned physician or supplier for services.
SIGNED: