Lowcountry Psychiatric Associates Joseph Walters, MD

Lowcountry Psychiatric Associates Joseph Walters, MD 25 Clarks Summit Drive--Suite F201 Richard Ford, MD Bluffton, SC 29910 Suzanne Veilleux, PhD (843) 757 4737 / Fax (843) 757-4585 Marianne Osentoski, PhD Vicki Bonnell, LISW-CP

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 ______

1 Signature ______Date______

2 NEW PATIENT HISTORY:

Current Symptoms/Problem Checklist: Please check any symptoms…. ( ) Depression ( ) Racing thoughts ( ) Excessive worry ( ) Substance Abuse ( ) Unable to enjoy activities ( ) Impulsivity ( ) Anxiety/Panic ( ) Family Issues ( ) Sleep disturbance ( ) Increase risky behavior ( ) Avoidance ( ) Legal Issues ( ) Loss of interest ( ) Increased/decreased libido ( ) Hallucinations ( ) Loss/Bereavement ( ) Concentration/Memory ( ) Decrease need for sleep ( ) Suspiciousness ( ) Pain Issues ( ) Change in appetite ( ) Excessive energy ( ) Excessive guilt ( ) Increased irritability ( ) Fatigue ( ) Crying spells

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: ______

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. ______3 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?______

4 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) 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. 2) 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: Mon- Thursday (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 3- 5 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 ______5 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 :______

6 Date:______

Lowcountry Psychiatric Associates Joseph Walters, MD 25 Clarks Summit Drive--Suite F201 Richard Ford, MD Bluffton, SC 29910 Suzanne Veilleux, PhD (843) 757 4737 / Fax (843) 757-4585 Marianne Osentoski, PhD Vicki Bonnell, LISW-CP

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: ______