New Patient Form

Your Name (required)

Patient Information Form + Office Policies and Procedures

Patient Information

Patient's Name:

Age:

Date of Birth (DOB):

Address:

City:

State:

Zip:

Social Security Number:

Sex:
MaleFemaleTransgender MaleTransgender FemaleNon Binary

Phone:

Text:

Preferred Contact Method: PhoneText

Email Address:

Employer/School:

Marital Status:
SingleMarriedDivorcedSeparatedPartner

Medical Doctor's Name:

Phone Number:

Have you consulted a psychiatrist before?

If so, name and address (optional):

Emergency Contact Name:

Relationship:

Phone Number:

Allergies/Reactions:

List of Current Medications:

Pharmacy Name:

Pharmacy Address:

Pharmacy Phone Number:

For Minors (if different from above)

Parent/Guardian's Name(s):

Parent/Guardian's Email:

Parent/Guardian's Cell Number:

Okay to leave a message? YesNo

Address:

City:

Zip:

Relationship to Patient: ParentLegal Guardian

Correspondence Information

Please initial below if you authorize our office to correspond with you via

Email: YesNo

Text: YesNo

Phone: YesNo

Initial:

Insurance Information

Insurance Carrier:

ID Number:

Group Number:

Subscriber Information:

• Subscriber's Name:

• Phone Number:

• Email:

• Address:

• Social Security Number:

• DOB:

Authorization: I, , authorize the release of any medical or other information necessary to process this claim. I also authorize payment of medical benefits to Austin Family Mental Health, PA.

Initial:

For patients over 18

If a parent/guardian is responsible for payment and you authorize us to speak to them about your account, please provide their information below:

Name:

Relationship:

Phone Number:

Address:

Email:

Payment for Services

At the time of care, I, , understand that payment will be required. Your appointment can be paid with cash or credit card. As a result of your signature on this form, you authorize our office to charge your credit/debit card on file for all services provided by this office, including copays/deductibles, missed appointments, late cancellation fees, telephone consultations, prescription fees, and non-urgent calls after hours. In the event that you wish to use a card different from what is on file at the time of service, please provide the new card information when you arrive for your appointment.

Initial:

HIPAA Privacy Policies

My signature below confirms that I have read and understand the office's HIPAA & Texas Privacy Policies. In addition, I agree that my Private Health Information may be transmitted via phone, fax, or email.

Signature: Clear

Patient/Guardian Date:

Notice of Privacy Practices

Health Insurance Portability and Accountability Act (HIPAA) April 14, 2003

Austin Family Mental Health is responsible for protecting the privacy of your personal and health information as described in this notice. Personal health information includes medical (or psychological) information and individually identifiable information such as your name, address, telephone number, or social security number. Austin Family Mental Health is required by applicable federal and state laws to maintain the privacy of your personal and health information (PHI).

Office Policies and Procedures

Welcome to our office. We appreciate the opportunity to serve you. Please read the following information carefully. If you have any questions or concerns, do not hesitate to ask a member of our staff or your provider. These policies are subject to change without notice.

Appointments

New Patients: The $100.00 deposit you paid to secure your new patient appointment will be forfeited if one of the following occurs:

— If you do not show up for your scheduled appointment,

— If you fail to provide 24 business hours notice of cancellation.

— If you are more than 10 minutes late to your appointment, which results in rescheduling.

In consideration of all patients, individuals who arrive 10 minutes late may need to reschedule.

Appointments must be canceled 24 business hours in advance to avoid a missed appointment fee.

Three missed or late cancellations will result in the discontinuation of our professional relationship.

Our EMR system will send courtesy appointment reminders 1-2 days prior to your scheduled appointment; however, it is ultimately the client's responsibility to attend scheduled follow-ups.

We encourage clients to make or move up an appointment when a complaint or problem occurs regarding their mental health and/or medication changes. Phone calls and emails to your provider may be assessed a fee.

Initial:

Billing and Payment

Payment (i.e., co-payment, co-insurance, deductibles, fee-for-service, and any balance) is due at the time of service. If you are unable to make a payment at the time of service, you may be asked to reschedule your appointment.

The information provided by your insurance company is not always accurate, and we encourage you to be informed about what benefits your insurance covers and your patient's responsibility.

Our office only submits claims to insurance companies for which we are "in-network." If you wish to file out-of-network with your insurance company, please inform our staff so they can provide you with an itemized statement.

It is important to communicate with our office if you have a change of insurance as most insurance companies have a 90-day filing deadline. Failure to provide accurate insurance information may result in your responsibility to pay in full for services provided.

Accounts with no payment activity for 90 days will be turned over to a collection agency. It is our policy that once an account is turned over, services are discontinued.

Initial:

Medication Refills

Prior to calling our clinic, we ask all patients to either have their pharmacy fax us a refill request and/or email their request to frontdesk@austinfamilymentalhealth.com. Please allow 2 business days to process your request.

Medications taken more than prescribed will be denied an early refill. If you would like to discuss a change in medication, please call the office to set up an appointment.

Texas law requires patients to be under medical supervision when taking controlled medications. Patients on controlled medications must also follow up with their provider every 90 days.

Prescriptions requested to be filled the same day will be assessed a $20.00 fee.

Our office will not refill medications outside of normal business hours.

There is a $12.00 fee to write controlled medications between appointments. Alternatively, you may come in monthly to obtain your medication.

All schedule II medications (Vyvanse, Adderall, etc.) must be filled within 21 days, or they will expire.

Stolen/lost controlled medications will not be refilled early, and patients will have to wait until they are eligible for another refill.

Note: Stimulants are not lifesaving medications, and running out does not constitute a medical emergency. Early refills are not permitted.

Initial:

Prior Authorizations

If your benefit company denies your medication and requires your provider to provide clinical documentation to approve a medication, you will be assessed a $25.00 fee. This is a very time-consuming task for the provider and staff. We highly suggest you speak with your benefit company if they continue to deny your medication. Please allow 72 business hours to process such requests. You may want to pay out-of-pocket if the medication is generic and affordable.

Initial:

Confidentiality

Our office understands the need to keep your information confidential, and we will act in good faith to keep your matters private. Please use caution when leaving us home/work/cell numbers and/or an email address to contact you. Please provide us with updated information to ensure your confidentiality is not jeopardized.

Our office requires a signed Release of Information to speak with family members, providers, disability companies, or anyone to whom you would like to have access to your information.

I accept, understand, and agree to abide by the contents and terms of this agreement and further, consent to participate in evaluation and/or treatment. I understand that I may withdraw from treatment at any time.

Printed Name:

Signature: Clear

Notice of Privacy Practices Acknowledgement

Patient/Client Name:

Relationship to Patient:

Signature of Patient/Client or Legal Guardian (if minor): Clear

Date:

OFFICE USE ONLY

I attempted to obtain the patient's signature in acknowledgment of this Notice of Privacy Practices Acknowledgment, but was unable to do so as documented below:

Date:

Initials:

Reason:

I hope this meets your requirements! Let me know if there are any additional changes or specific details you'd like to include.