Washington Center for Women’s and Children’s Wellness, LLC
6430 Rockledge Drive, Suite 218, Bethesda, MD20817
Phone: 301-881-9464 Fax: 301-881-9298
Name: ______Date: ______
Home Address: ______DOB: ______
City: ______State ______Zip Code: ______
Mobile/Cell Phone: ______Other Phone: (please specify) ______
Email address: ______Preferred method of contact: ______
Emergency Contact Name ______Number: ______
Relationship: ______
Are you currently taking any medications? Yes No
If yes, please list each medication, dose, and prescriber’s name: ______
______
______
Are you allergic to any medications? Yes No
If yes, please list each medication, your reaction, and date (if known): ______
______
Are you currently seeing a mental health professional (Psychiatrist, Psychologist, Therapist)? Yes No
If yes, please list each provider, type of treatment and length of time in treatment: ______
______
______
How did you learn about this practice? ______
Who is your Primary Care Physician? Please provide his or her name, address, and phone number:
______
______
Our mission is to help you attain complete wellness. We believe that collaboration with your other physicians and therapists can be of great benefit to us in caring for you. However, we also believe very strongly in your right to confidentiality. In keeping with our policies, we will not contact anyone about you without your written permission.
Washington Center for Women’s and Children’s Wellness, LLC
6430 Rockledge Drive, Suite 218, Bethesda, MD20817
Phone: 301-881-9464 Fax: 301-881-9298
We would like to welcome you to our office. The following is information about office policies we think you may find useful. After you have had the opportunity to review our policies, please sign two copies, and keep one for your records.
If you call our office for routine (appointments, refills, cancellation) and the phone is not answered, please leave a message with your full name, reason for calling, and both day and evening numbers and your call will be returned as quickly as possible.
Fees for patients of Victoria Shampaine, M.D.
Adult Initial Psychiatric Evaluation (50-60 minutes) ------$350.00
Child &Adolescent Initial Psychiatric Evaluation (75 minutes) ------$375.00
Medication Management (20-25 minutes) ------$200.00
Psychotherapy 45-50)------$275.00
Fees for patients of Stephanie Ayala, RD, LDN
Initial Nutrition assessment (60 minutes)------$145.00
Follow-upNutrition session (25-30 minutes)------$ 85.00
Follow-upNutrition session (50-60 minutes) ------$125.00
10 Week Group (90 min) ------$750.00
Fees for patients of Julie Mitchell, LGPC
Adult Initial Evaluation (50-60 minutes) ------$150.00
Child &Adolescent Initial Evaluation (75 minutes) ------$175.00
Individual Session (45-50 minutes) ------$100.00
Family Session (90 minutes) ------$125.00
10 Week Group (90 min) ------$750.00
Fees for patients of Lisa Luse, LCSW-C, LICSW
Adult Initial Evaluation (60 minutes) ------$225.00
Child &Adolescent Initial Evaluation (75 minutes) ------$275.00
Individual Session (45-50 minutes) ------$145.00
Family Session (60 minutes) ------$175.00
10 Week Group (90 min) ------$950.00
Insurance:
We don’t accept direct payment from any insurance company, but we want you to receive all of the insurance reimbursement to which you are entitled. The surest way to accomplish this goal is for you to pay in full at the time of each visit, file your claim and accept your reimbursement from the carrier. If you have trouble with this, your employer or benefits manager may be able to help.
We do not accept Medicare or Medicaid and can’t legally see Medicare patients.. A statement will be given to you after each visit providing diagnosis, CPT code and breakdown of charges for each visit. If your insurance company (or anyone else) requires further information, we will provide it promptly but only after receiving your written consent.
Payments
* All payments due at the time of visit. No exceptions.
* Payment can by made cash, check, or credit card
* There will be a $25.00 fee for returned checks.
* In the event your account has to be turned over to a collection agency, you will be responsible for fees incurred as a result.
* Minors who are not accompanied by parents for each visit must have credit card information on file with a signed authorization to charge card for each session.
* Patients scheduling a Phone Session must providepayment card information at the time of scheduling an appointment.
* All personal and payment information is protected by password.
Signature______Date: ______
Revised November 2015
Washington Center for Women’s and Children’s Wellness, LLC
6430 Rockledge Drive, Suite 218, Bethesda, MD20817
We would like to welcome you to our office. The following is information about office policies we think you may find useful. After you have had the opportunity to review our policies, please sign two copies, and keep one for your records.
If you call our office for routine (appointments, refills, cancellation) and the phone is not answered, please leave a message with your full name, reason for calling, and both day and evening numbers and your call will be returned as quickly as possible.
Fees for patients of Victoria Shampaine, M.D.
Adult Initial Psychiatric Evaluation (50-60 minutes) ------$350.00
Child &Adolescent Initial Psychiatric Evaluation (75 minutes) ------$375.00
Medication Management (20-25 minutes) ------$200.00
Psychotherapy 45-50)------$275.00
Fees for patients of Stephanie Ayala, RD, LDN
Initial Nutrition assessment (60 minutes)------$145.00
Follow-upNutrition session (25-30 minutes)------$ 85.00
Follow-upNutrition session (50-60 minutes) ------$125.00
10 Week Group (90 min) ------$750.00
Fees for patients of Julie Mitchell, LGPC
Adult Initial Evaluation (50-60 minutes) ------$150.00
Child &Adolescent Initial Evaluation (75 minutes) ------$175.00
Individual Session (45-50 minutes) ------$100.00
Family Session (90 minutes) ------$125.00
10 Week Group (90 min) ------$750.00
Fees for patients of Lisa Luse, LCSW-C, LICSW
Adult Initial Evaluation (60 minutes) ------$225.00
Child &Adolescent Initial Evaluation (75 minutes) ------$275.00
Individual Session (45-50 minutes) ------$145.00
Family Session (60 minutes) ------$175.00
10 Week Group (90 min) ------$950.00
Insurance:
We don’t accept direct payment from any insurance company, but we want you to receive all of the insurance reimbursement to which you are entitled. The surest way to accomplish this goal is for you to pay in full at the time of each visit, file your claim and accept your reimbursement from the carrier. If you have trouble with this, your employer or benefits manager may be able to help.
We do not accept Medicare or Medicaid and can’t legally see Medicare patients.. A statement will be given to you after each visit providing diagnosis, CPT code and breakdown of charges for each visit. If your insurance company (or anyone else) requires further information, we will provide it promptly but only after receiving your written consent.
.
Payments
* All payments due at the time of visit. No exceptions.
* Payment can by made cash, check, or credit card
* There will be a $25.00 fee for returned checks.
* In the event your account has to be turned over to a collection agency, you will be responsible for fees incurred as a result.
* Minors who are not accompanied by parents for each visit must have credit card information on file with a signed authorization to charge card for each session.
* Patients scheduling a Phone Session must providepayment card information at the time of scheduling an appointment.
* All personal and payment information is protected by password.
Signature______Date: ______
Revised November 2015
Washington Center for Women’s and Children’s Wellness, LLC
6430 Rockledge Drive, Suite 218, Bethesda, MD 20817
Phone: 301-881-9464 Fax: 301-881-9298
Policy for visits and refills
Visits:
As specialists in Psychopharmacology, our physicians will closely manage any medication they may prescribe for you by scheduling your office visits as often as needed until you are well and then by scheduling maintenance visits to keep you well till you and your doctor agree than you have reached your goals. Should you choose to have our physicians manage your medication and refill your prescriptions, we ask that you visit every 3months at minimum. Your General practitioner or another psychiatrist may feel comfortable with less frequent visits. If you choose, we can discharge you and transfer your records.
If for any reason you have not had a session with your physician and need a refill without changes after 3 months, we will schedule a 5 minute phone appointment with your doctor at a cost of $185. If you are not doing well and need any prescription changes you will need to schedule a full phone session. Any patient who has not been seen for 12 months will be considered a new patient.
If you are late for your appointment, our physician will be still able to see you for the time remaining of your session. You will be billed for the time of the original appointment. If you arrive after your session is fully over we will be more than happy to reschedule your appointment; however you will be billed for missed session.
Weigh Policy:
I agree to be weighed prior to all nutrition sessions. I understand that I have the option to not see my weight and will let the dietitian know if this is my desire prior to being weighed. I understand that I will be asked to remove excess clothing and accessories including items such as shoes, coats, scarves, jewelry and belts."
Prescription refills:
Because we require visits every 3 months and refill medications at each visit you should not need to routinely call for prescription refills. If for any reason, you find you do need refills between appointments, please call at least 72hours before you will run out of medicine and leave the following information: your name, date of birth, phone number, medication name, dose, frequency and pharmacy number.
Because your physician may be out of the office and away from her records, there is a 3-business day turnaround time required for prescription refill processing.
If “emergency” prescriptions are required between appointments more than twice a year a fee of $150.00 will be charged.
Controlled substance prescriptions must be picked up at the office or sent by certified mail for a fee of $8 (card information required to be on file)
Cancellation & Closure Policy:
If you need to cancel your appointment for any reason, it is important that you leave a message at least 48 hours (2 business day) prior to that appointment – otherwise, you will be charged for the appointment time.
During winter months, if MCPS are closed or delayed due to an inconvenient weather, each physician will make their own decision regarding if the office will stay open. You will be contacted by our office and rescheduled if necessary
Our office will be closed on following holidays: Memorial Day, Independence Day, Labor Day, Thanksgiving Day & Black Friday, December 24 & December 25 and New Years Day.
Signature______Date: ______
(Office Copy)
Washington Center for Women’s and Children’s Wellness, LLC
6430 Rockledge Drive, Suite 218, Bethesda, MD 20817
Phone: 301-881-9464 Fax: 301-881-9298
Policy for visits and refills
Visits:
As specialists in Psychopharmacology, our physicians will closely manage any medication they may prescribe for you by scheduling your office visits as often as needed until you are well and then by scheduling maintenance visits to keep you well till you and your doctor agree than you have reached your goals. Should you choose to have our physicians manage your medication and refill your prescriptions, we ask that you visit every 3months at minimum. Your General practitioner or another psychiatrist may feel comfortable with less frequent visits. If you choose, we can discharge you and transfer your records.
If for any reason you have not had a session with your physician and need a refill without changes after 3 months, we will schedule a 5 minute phone appointment with your doctor at a cost of $185. If you are not doing well and need any prescription changes you will need to schedule a full phone session. Any patient who has not been seen for 12 months will be considered a new patient.
If you are late for your appointment, our physician will be still able to see you for the time remaining of your session. You will be billed for the time of the original appointment. If you arrive after your session is fully over we will be more than happy to reschedule your appointment; however you will be billed for missed session.
Weigh Policy:
I agree to be weighed prior to all nutrition sessions. I understand that I have the option to not see my weight and will let the dietitian know if this is my desire prior to being weighed. I understand that I will be asked to remove excess clothing and accessories including items such as shoes, coats, scarves, jewelry and belts."
Prescription refills:
Because we require visits every 3 months and refill medications at each visit you should not need to routinely call for prescription refills. If for any reason, you find you do need refills between appointments, please call at least 72hours before you will run out of medicine and leave the following information: your name, date of birth, phone number, medication name, dose, frequency and pharmacy number.
Because your physician may be out of the office and away from her records, there is a 3-business day turnaround time required for prescription refill processing.
If “emergency” prescriptions are required between appointments more than twice a year a fee of $150.00 will be charged.
Controlled substance prescriptions must be picked up at the office or sent by certified mail for a fee of $8 (card information required to be on file)
Cancellation & Closure Policy:
If you need to cancel your appointment for any reason, it is important that you leave a message at least 48 hours (2 business day) prior to that appointment – otherwise, you will be charged for the appointment time.
During winter months, if MCPS are closed or delayed due to an inconvenient weather, each physician will make their own decision regarding if the office will stay open. You will be contacted by our office and rescheduled if necessary.
Our office will be closed on following holidays: Memorial Day, Independence Day, Labor Day, Thanksgiving Day Black Friday, December 24 & December 25 and New Years Day.
Signature______Date: ______
(Patient Copy)
Washington Center for Women’s and Children’s Wellness, LLC
Consent Agreement
Consent to the Use and Disclosure of Health Information
For Treatment, Payment, or Healthcare Operations
I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
- A basis for planning my care and treatment
- A means of communication among the health professionals who contribute to my care
- A source of information for applying my diagnosis and medical information to my bill
- A means by which a third-party payer can verify that services billed were actually provided
- And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals
I understand and have been provided with a Privacy and Confidentiality Practices formthat provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have a right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.
I request the following restrictions to the use or disclosure of my health information:
______
______
______
Signature of Patient or Legal Representative Witness:
Notice:
______Accepted______Denied
Signature: ______
Date: ______
Washington Center for Women’s and Children’s Wellness, LLC
Authorization for Release of Medical Records and
Provider Collaboration
I hereby authorize my WCWCW provider to share my medical and psychiatric records with these individuals or group practices:
Name(s) of provider(s): ______
______
______
I hereby authorize and request you to release information to WCWCW, LLC.
Washington Center for Women’s and Children’s Wellness, LLC
(Attn: Name of provider ______at WCWCW)
Westmoreland Building
6430 Rockledge Drive, Suite 218
Bethesda, MD 20817
Office phone (301) 881-9464 Fax (301)881-9298
The complete medical records in your possession, concerning my treatment during the period from ______to ______. My treatment may also be discussed on the telephone or secure email. This authorization shall remain in effect for one year unless I notify WCWCW, LLC of my wish to terminate the authorization.
(Your Name) ______Date of Birth ______
(Your Address) ______
______
(Your Signature) ______
Date Release signed ______
Washington Center for Women’s and Children’s Wellness, LLC
Authorization for Release of Medical Records and
Provider Collaboration
I hereby authorize my WCWCW provider to share my medical and psychiatric records with these individuals or group practices:
Name(s) of provider(s): ______
______
______
I hereby authorize and request you to release information to WCWCW, LLC.
Washington Center for Women’s and Children’s Wellness, LLC
(Attn: Name of provider ______at WCWCW)
Westmoreland Building
6430 Rockledge Drive, Suite 218
Bethesda, MD 20817
Office phone (301) 881-9464 Fax (301)881-9298
The complete medical records in your possession, concerning my treatment during the period from ______to ______. My treatment may also be discussed on the telephone or secure email. This authorization shall remain in effect for one year unless I notify WCWCW, LLC of my wish to terminate the authorization.