New Patient Paperwork

Cornerstone Psychiatry Associates

Practice Information & Consent Form

 

 

PLEASE PRINT ALL INFORMATION

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: (______) ________________

 

ID#:__________________________________________     

 

Group#:___________________________________________

 

 

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. 
 
NO SHOWS/CANCELLATIONS
 
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