Smita H. Patel, M.D. DFAPA
730 24th St, NW Suite 10 Washington DC 20037
202-775-0620
Patient Information:
Name: Last:______First:______
D.O.B.______Email______
Address______City______State______Zip______
Telephone: (H)______(W)______(C)______
Marital Status (circle) S M W Se D Spouse Name______
PLEASE INDICATE IF MESSAGES CAN BE LEFT OR MAIL SENT
Home phone yes noCellular Phone yes no
Work phone yes noHome Address yes no
Employer Name______Occupation______
Street Address______City______State______Zip______
Primary Care Physician
Name ______Phone______
Street Address______City______State_____Zip______
Do we have your permission to coordinate care with your Primary Care Physician? yes no
Insurance:
Primary Policy
Name of Insured______
Insurance Company______Policy #______
Secondary Policy
Name of Insured______
Insurance Company______Policy #______
Emergency Contact:
Name______Phone______Relationship______
Address______
If under 18, legal guardian
(name, address, phone number)
______
SignatureDate
Appointments:
The normal practice’s hours are (M-F 8:30am to 5:30 pm). In theevent of an emergency, your psychiatrist or therapist may be reached by answering service at (240) -638-9750. Ifyou are unable to reach your psychiatrist or therapist, you may call your primary care physician or thelocal emergency room. In the event of a life-threatening emergency, please call 911 or proceed to your nearest emergency room.
If personal information (such as address, telephone number and insurance information) changes, it is the patient’s responsibility to inform us of these changes as soon as possible. Dr. Patel’s office will not be responsible for charges associated with failure to inform for such changes.
Confidentiality:
Provider-patient communication is governed by many rules of confidentiality. In particular, provider-patient communication is confidential with the exception of circumstances which may result in harm to the patient or another individual.
With respect to charts and written communication, Dr. Patel maintains patient records that are not released to anyone without the consent of the patient (or his/her family if patient is a minor). Patient records/files are retained for the statutory period at minimum. Copies of charts (or treatment summaries in the case of request for psychotherapy notes) will be made available as necessary for a minimal fee.
Payments:
All payments are due at the time of the visit. Your doctor willfile your insurance claim, but you are responsible for deductibles, co-insurance, and co-payments. It isyour responsibility to familiarize yourself with your insurance policy and benefits.
Cancellations and Missed Appointments:
You will be billed for a sessions that you cancel with less than 48hours’ notice. You may leave messages
24 hours per day. You will be billed $60.00for any no show visit. Insurance companies donot reimburse for failed appointments.
Consent for Treatment
By signing below, you are stating that you have read and understood this policy statement and you
have had your questions answered to your satisfaction.I accept, understand and agree to abide by the contents and terms of this agreement and further, consent toparticipate in evaluation and/or treatment. I understand that I may withdraw from treatment at any time.
Termination of Treatment:
Patients of Dr. Patel who have not been seen in office for one hundred twenty (120) days (or within mutually agreed upon time at the last session, if longer than 120 days), will be considered inactive and will have their file closed, thereby ending any provider-patient responsibility on the part of Dr. Patel. Please be assured that anyone wishing to return for treatment can do so and their file will have reopened and activated.
Prescription Refill Requests:
All prescription refills should be requested at least ONE WEEK in advance. We cannot guarantee that your refill will be filled if we are not given that amount of time, as the doctor must be available to approve the refill. Please be sure to get refills at your appointment that will last until your next appointment time; the patient will be responsible for ensuring that the appointment is scheduled in a timely fashion so as to avoid running out of medication.
You may request a refill by:
- Asking your pharmacist to fax a request to us at 301-754-3695
- Leaving a voice message in mailbox or speaking to the receptionist
Refills needing to be called in with less than 24 hour notice will be handled as quickly as possible. However, we will reserve the right to charge a $20 fee if this request is made on more than one occasion.
It is the policy ofDr. Patel that patients on medication be seen at regular intervals to ensure patient safety. Please do not stop your medication without speaking to your doctor first, as certain medications can have discontinuation syndromes.
Extended Terms of Treatment:
Dr. Smita Patel provides comprehensive psychiatric evaluations and psychopharmacological management with supportive psychotherapy. She does not provide intensive individual psychotherapy or psychoanalysis. Dr. Patel will make recommendations to licensed psychotherapists and coordinate your treatment plan (PhD or LCSW) if requested or advised. Please be aware that Dr. Patel is not a psychotherapist.
Name of patient or authorized person (please print) ______
Signature: ______
Date: ______
Office staff/Witness: ______
Page 1 of 3