New Patient Paperwork

Cornerstone Psychiatry Associates

Practice Information & Consent Form




Section I:                                                        Patient Information                                       Date______________


Last Name: _____­­­­­_________________________   First Name: _________________________ MI: ________


Address: __________________________________________________________________________________________


City: ________________________________             State: ________               Zip: ______________________


Date of Birth: ___________________          Age: ________                                  Gender:  c Male  c Female  


DL State: _______________   DL# _____________________   SS# _______________________________


Home Phone (______) __________­_   Work Phone (______) __________   Cell Phone (______) ____________


What is the best contact number? c Home c Work c Cell Can we leave a detailed message? c Yes c No  

Check Appropriate Box:    c Minor     c Single     c Married     c Widowed     c Separated     c Divorced


Occupation: ___________________   Employer: ________________    Work Phone (______) ______________


If Student, Name of School_______________________________   c Full   c Part   City/State _____________________          



Section II                                                        Responsible Party




Relationship to Patient:   c Self      c Spouse      c Parent      c Other


Last Name: _____­­­­­_________________________   First Name: __________________________ MI: ________ 


Date of Birth: ___________________         Age: ________                                   Gender:  c Male  c Female  


DL State: ___________   DL# ____________________________   SS# _______________________________


Address: __________________________________________________________________________________________


City: _________________________________             State: _______               Zip: ______________________


Home Phone (______) _________­_   Work Phone (______) __________   Cell Phone (______) _____________


Occupation: ________________   Employer: __________________    Work Phone (______) ______________


Address of Employer: ________________________________________________________________________________


City: _________________________________             State: _________________               Zip: ______________________



Section III                                                       Insurance Information


Subscriber Name: ____________­­­_________________     Relationship to Patient: _____________________   


SS#:___________________________                                           Date of Birth: ­­­__________________________


Employer: ____________________________                                Work Phone: (______) ________________


Address of Employer: ________________________________________________________________________________


City: _________________________________             State: ________             Zip: ______________________


Insurance Company: ___________________________               Ins. Co. Phone: (______) ________________







Referred By: ____________________________     Reason For Visit: ____________________________


Cornerstone Psychiatry Associates

Practice Information & Consent Form



We are committed to providing you with the best possible care.  This office only takes a limited number of insurance plans Please check with a member of the office staff, to see if your plan is one that is accepted. If we are contracted with your plan, we will be happy to file your insurance. If we are not contracted with your plan, this will be fee for service and Payment for services is due at the time services are rendered.  We will be happy to provide you with a receipt which you may then file to you insurance company for out of network benefit reimbursement.
There will be a $31.87 service charge levied on all returned checks. 
When a patient does not show or cancels appointments on the same day, other patients are denied an appointment.  If you cannot make or keep and appointment, the office policy is:
1. There is No Charge for Cancellations 24 Hours Prior To the Scheduled Appointment.
2. There is a $25.00 charge if an appointment is cancelled within 24 hours of your scheduled appointment.
3. You will be charged full appointment fee if you “NO SHOW” or do not call to cancel.
***As a courtesy to our patients, we try to confirm all appointments in advance. However this courtesy is not always possible and in no way defers the responsibility.  You are responsible for keeping or cancelling any appointments scheduled.***
 ***New patients are booked for one hour appointments. Follow-up visits (medication management) are booked for fifteen minute appointments.***
 There will be times when patients are in crisis, and may need extra appointment time. Please be understanding if the doctor runs late. Please be assured when you need extra time during your appointment, you will receive it.
Phone Calls:
Phone calls will usually be answered by a member of the office staff at the end of the workday, or the following day. Insisting on speaking with the Dr. for non-emergent calls will be subject to a charge. Calling multiple times will not expedite this process. Calls will be returned as soon as possible. If someone is having a life-threatening emergency, please let the staff know, and the physician will be notified immediately.
When calling to leave a message, please be courteous with staff members. They have been instructed to obtain as much information as possible, so that the physician is well-equipped to answer these calls. They must also have information, so that calls may be triaged properly. We understand that some matters are very delicate, but the staff is professional, and will keep these issues in confidence.
If you have not had an office visit in three months, and call with issues, you will be asked to make an appointment as soon as possible. Generally, major alterations in medications will not be made over the phone, and you may be asked to make an appointment.
Calling the physician’s emergency line after hours or on weekends for non-emergent issues will result in a $45 fee.
I have read and understand the policies of Cornerstone Psychiatry Associates
 Patient/Parent or Guardian Signature                                                                   Date