Download Lowcountry Psychiatric Associates Joseph Walters, MD 25 Clarks

Lowcountry Psychiatric Associates
Joseph Walters, MD
Richard Ford, MD
Suzanne Veilleux, PhD
Marianne Osentoski, PhD
Vicki Bonnell, LISW-CP
25 Clarks Summit Drive--Suite F201
Bluffton, SC 29910
(843) 757 4737 / Fax (843) 757-4585
Name___________________________________
Today’s Date_______________________
DOB_______________________
SSN__________-_______-_________
Phone______________________
Email Address ______________________________________
Address__________________________________________________________________________
Referred by __________________ Primary Physician ________________________ Pharmacy ____________
Emergency Contact _______________________ Relation: __________________ Tel.# ______________
BILLING / INSURANCE INFORMATION:
Responsible party information:
Subscriber Name / DOB ________________________________________
Subscriber SSN________________________
Insurance Company___________________________________________ Policy Number___________________________
Group Number_________________________________ Managed care authorization number______________________
If Name Different from patient:
Name__________________________________________ Relation to Patient:___________________________________
Address____________________________________________________ Phone_________________________________
GUARANTOR INFORMATION: (Guarantor is the person responsible for the balance after insurance pays on the account. If
18 or older you are your own guarantor, if the patient is under 18 it is the person that brings them in for their
appointment.)
Guarantor Name: _______________________________________ Relationship to Patient: ________________________
Guarantor SS#: _________________________________________ Guarantor Phone#: ____________________________
Guarantor Address __________________________________________________________________________________
Guarantor Employer: ________________________________________________________________________________
Employer Phone#: ____________________________________________
DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS
YOUR MEDICAL CONDITION? YES______________
NO_______________
IF YES, WHOM? ________________________________________________________
Printed Name
______________________________________________
Signature
______________________________________________
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Date_________________________
NEW PATIENT HISTORY:
Current Symptoms/Problem Checklist: Please check any symptoms….
(
(
(
(
(
(
(
) Depression
) Unable to enjoy activities
) Sleep disturbance
) Loss of interest
) Concentration/Memory
) Change in appetite
) Increased irritability
(
(
(
(
(
(
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) Racing thoughts
) Impulsivity
) Increase risky behavior
) Increased/decreased libido
) Decrease need for sleep
) Excessive energy
) Fatigue
(
(
(
(
(
(
(
) Excessive worry
) Anxiety/Panic
) Avoidance
) Hallucinations
) Suspiciousness
) Excessive guilt
) Crying spells
(
(
(
(
(
) Substance Abuse
) Family Issues
) Legal Issues
) Loss/Bereavement
) Pain Issues
OTHER:___________________________________________________________________________________
Suicide Risk
Have you ever tried to harm yourself in the past? ( ) Yes ( ) No.
Have you had any recent thoughts, or do you currently have any thoughts of suicide? ( ) Yes ( ) No.
Medical History:
Allergies___________________________________________ Current Weight ____________ Height _______
List ALL current medications and how often you take them/dosage:
____________________________
____________________________
____________________________
____________________________
____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_______________________________
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Current over-the-counter medications or supplements:___________________________________________
Current/Past major medical problems (chronic illness, surgeries, hospitalizations…)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
For women:
Date of last menstrual period: _______Are you currently, or do you think you are pregnant?( )Yes( ) No.
Are you planning to get pregnant in the near future? ( ) Yes ( ) No
Family History (Medical/Psychiatric Diagnoses, Substance Abuse or Self-Injury/Suicide):
____________________________________________________________________________________
____________________________________________________________________________________
Past Psychiatric History
Outpatient treatment ( ) Yes ( ) No. If yes, Please describe when, by whom, and nature of treatment.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Psychiatric Hospitalization ( ) Yes ( ) No If yes, describe for what reason, when and where.
____________________________________________________________________________________
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Past Psychiatric Medications: If you have ever taken any of the following medications (please circle).
Mood/Thoughts: Viibryd, Brintilex, Fetzima, Saphris, Latuda, Invega, Risperdal, Prozac, Zoloft, Luvox, Paxil, Celexa, Lexapro,
Viibryd, Effexor, Cymbalta,Wellbutrin, Remeron, Serzone, Anafranil, Pamelor,Tofranil, Elavil, Tegretol, Lithium, Lamictal, Tegretol,
Topamax, Seroquel, Zyprexa, Geodon, Abilify, Clozaril, Haldol, Prolixin
Sleep: Ambien, Lunesta, Sonata, Rozerem, Restoril, Desyrel/trazodone
ADHD: Adderall, Concerta, Ritalin, Vyvanse, Focalin, Dexedrine, Strattera
Anxiety: Xanax, Ativan, Klonopin, Valium, Restoril, Librium,Tranxene, Buspar, Vistaril, Benadryl, Propranolol
Other: ______________________________________________________________________________
Any negative/positive experiences with these medications? ____________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Substance Use:
Do you (or others) think you may have a problem with alcohol or drug use? ( ) Yes ( ) No
Have you ever been treated for alcohol or drug use or abuse? ( ) Yes ( ) No
If yes, for which substances and when/where were you treated? ________________________________
Days/wk drinking alcohol: _____ Avg. Number drinks/day: _________ Most drinks/day: ___________
Do you have current/past problems with the use/abuse of illegal substances? If so, which substances?
____________________________________________________________________________________
Have you abused prescription medication? If so, which medications? ____________________________
How many caffeinated beverages do you drink a day? Coffee _____ Sodas ________ Tea ___________
Tobacco History: active__________________________ past________________________________
Family Background and Childhood History:
Where were you born___________________________ where did you grow up ________________________
Were you adopted? ( ) Yes ( ) No
Did your parents’ divorce? ( ) Yes ( ) No Your age at their divorce:_______ you lived with___________________
List your siblings and their ages: Sisters (ages)______________________________________________________
Brothers (ages)________________________________________________________________________________
Educational History:
What is your highest educational level or degree attained? _____________________________________
Spiritual life: Do you belong to a particular religion or spiritual group? __________________________
Trauma History:
Do you have a history of being abused emotionally, sexually, physically or by neglect? ( ) Yes ( ) No.
____________________________________________________________________________________________
Occupational History:
Are you currently: ( ) Working ( ) Not working by choice ( ) Unemployed ( ) Disabled ( ) Retired
What is/was your occupation? __________________________________________________________________
Have you ever served in the military? _______ If so, what branch and when? _____________________________
Relationship History and Current Family:
Are you currently: ( ) Married ( ) Divorced ( ) Single ( ) Widowed
How long? _____ Total number of marriages?______
If not married, are you currently in a relationship? ( ) Yes ( ) No If yes, how long? _________________________
Do you have children? ( ) Yes ( ) No. If yes, list ages and gender_______________________________________
Legal: Have you ever been arrested? _______ Do you have any pending legal problems?___________________
___________________________________________________________________________________________
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Lowcountry Psychiatric Associates – Financial Contract/Office Policies
I)
Payment Arrangements
a)
Patients of Dr. Ford & Dr. Walters
Dr. Ford and Dr. Walters are private ‘fee for service’ providers, do not contract with any insurance companies, do not accept Medicaid and
have opted out of Medicare. Payment is due in full at the time services are provided. Patients cannot file claims to Medicare for services
provided (just as providers cannot bill Medicare, given opt out status). Fees for service are mutually agreed upon, based upon fee schedule
provided.
If you have insurance coverage and wish to use it, you should contact your insurance company representative to obtain forms and coverage
information. The insurance contract is between you and the insurance company. Therefore, you remain responsible for all payments directly
to the physician, and the insurance company may reimburse you directly (if your policy provides such coverage/reimbursement, once you
self-file a claim). The office will gladly provide you a statement which may be utilized for an insurance claim, upon request.
b)
Patients of Dr. Veilleux, Dr. Osentoski & Mrs. Bonnell
1)
2)
Insurance (Provider in-network; “provider”)
In these cases, the provider is contracted with your insurance company. Fees are reimbursed at the usual and customary rate allowed by
this contract. Provided that services have been properly pre-authorized, you are responsible for the co-payment which you are expected
to pay at the time of service. This fee may vary at times, based upon your insurance contract. If your deductible has not yet been met,
you will need to pay the full fee for each session until satisfied. In the event the insurance company does not pay the bill, the balance
will become the patient’s responsibility.
Insurance (Provider out of network; “non-provider”)
In these cases, the provider is not contracted with your insurance company, and you are being seen on a ‘fee for service’ basis. That
said, if you have insurance coverage and wish to use it, we will file your insurance claim for you, as a courtesy. However, you will be
responsible for the full amount of charges, due when services are provided.
For those patients utilizing insurance for care, there are some services that may not be covered by insurance, and payment remains the responsibility of
the patient. Examples include, but are not limited to, fees for:
 missed appointments
 extended-time appointments
 psychological testing
 phone calls
 filling out paperwork or providing letters (i.e. school, work, disability, etc.)
*Charges for services, such as those above, are based on the amount of time required in there provision (with the exception of psychological testing).
Test fees would be discussed at time of scheduling, based upon what is needed.
*You agree to fees set forth by LPA. Fees are subject to change in the future, but fee changes do not void this contract. This agreement remains in
force, for as long as you are provided care in our office.
Policy re: Late/Missed Appointments
Patients are charged based on the type of appointment scheduled. Failure to give at least 24 hours’ notice (to reschedule) will result in a full charge for
the visit. For patients utilizing insurance, you will be required to pay for the missed session (not covered by insurance), even if you normally only pay a
co-pay. You can leave a voicemail at any time to cancel an appointment within 24 hours. Voicemail must be left within business hours: MonThursday (8am-5pm), Friday (8am-Noon).
Policy re: Medication Refills
Prescription refills are routinely handled during clinic visits with your provider, during session. Your provider will prescribe you enough medication to
last until the next recommended appointment. Patients are typically seen monthly initially, but gradually this frequency may be reduced to quarterly
visits, if the patient doing well and stable on a medication regimen. However, if controlled medications are prescribed, this may result in continued
monthly appointments.
If a prescription refill is needed outside of a normal office visit, please contact your pharmacy and have them fax a refill request to your provider. Note
that your provider may require you to make an appointment, prior to getting any refills. Please allow 72 hours for refill requests (thus make requests 35 days before you would run out of medication). Refill requests will generally not be handled outside of office hours. There will be a charge of $25 for
‘urgent’ requests given with less than 72 hours’ notice, and/or refills provided outside of normal business hours.
Policy re: Phone Calls
Providers typically return routine/non-urgent calls-messages left at the office within 24 hours of receiving the message. That said, our policy is to
provide quality patient care through scheduled office visits, and you may be directed to schedule an appointment to address your concern. If you have
an urgent matter that cannot wait until regular office hours or your next appointment, you may call our after-hours number (866-256-4501) to contact a
provider. Phone calls may be charged, with fees based upon the nature and duration of the call.
My signature indicates that I have read and understand this fee agreement, as well as office policies. I agree to take full responsibility for fees
in accordance with that outlined above.
Printed Name ______________________________
Signature ______________________________________ Date ______________
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Confidentiality
The patient/provider relationship is privileged and protected by law, as well as ethical standards. Ordinarily,
no information can be released without your specific written approval. Certain legal circumstances can arise
whereby written documents can be subpoenaed. In addition, we are mandated to report to Protective Services
any suspicion of abuse of a child in the care of an adult, or the abuse of disabled person. A provider may also
break confidentiality if he/she feels there is an acute danger to the patient (or a danger to a potential victim).
Insurance companies may require diagnostic/treatment information before they will agree to pay benefits. By
utilizing insurance in our practice, you are giving permission to LPA to provide this clinical/personal
information for claims processing.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I hereby acknowledge that a copy of LPA Notice of Privacy Practices, which describes how my health information is used
and shared, has been made available to me. I understand that LPA has the right to change this Notice at any time. I may
obtain a current copy by contacting LPA Privacy Official, Allison Herring, or by visiting LPA’s website at:
http://www.lowcountrypsych.com.
__________________________________________________
Signature of Patient or Personal Representative
________/_______/_______
Date
____________________________________________________________________________
Print Name
____________________________________________________________________________
Personal Representative’s Relationship to Patient
For Lowcountry Psychiatric Associates Use Only
Complete this section if this form is not signed and dated by the patient or patient’s personal
representative.
I have made a good faith effort to obtain a written acknowledgement of receipt of Lowcountry
Psychiatric Associates’ Notice of Privacy Practices but was unable to for the following reason:
□ Patient refused to sign
□ Patient unable to sign
□ Other ____________________________________________________________________
____________________________________________
Employee Name
_________________________
Date
Emergencies
In the event of an emergency, please do not call the office or after hours line. Go to the nearest Emergency Room or
dial 911 immediately.
My signature indicates that I have read and understand the limits to confidentiality.
Printed Name: _____________________________
Signature :________________________________
Date:_______________________________
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Lowcountry Psychiatric Associates
Joseph Walters, MD
Richard Ford, MD
Suzanne Veilleux, PhD
Marianne Osentoski, PhD
Vicki Bonnell, LISW-CP
25 Clarks Summit Drive--Suite F201
Bluffton, SC 29910
(843) 757 4737 / Fax (843) 757-4585
CONSENT & AUTHORIZATION TO REQUEST AND RELEASE CONFIDENTIAL INFORMATION
Client’s Name:________________________________________________________________________
DOB:______________________________ _ SS#:___________________________________________
Address:_____________________________________________________________________________
I hereby authorize the request and/or release and disclosure of pertinent information from my psychological records to
and/or from:
Dr. Walters
Dr. Ford
Dr. Veilleux
Dr. Osentoski
Mrs. Bonnell
to and/or from the following individuals/organizations:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Address:______________________________________________________________________________
______________________________________________________________________________________
Relationship to Client:___________________________________________________________________
PORTION OF THE PSYCHOLOGICAL RECORD TO BE DISCLOSED AND/OR RELEASED:
 medical records
 discharge summary  history and physical  progress notes  laboratory results
 entire chart including past psychiatric care  diagnoses  plan & progress summaries
I understand that my records are protected under the Federal Confidentiality Regulations as well as the provision of
HIPAA (Health Insurance Portability and Accountability Act of 1996) and cannot be disclosed without my written consent
unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time, provided
that action has not been taken in reliance upon this authorization.
Date: _____________________
Client’s signature: ____________________________________________
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