form test - Malinas MD

Personal Information
Patient's Name*
First Last
SSN*
Sex*
- Male
- Female
Date of Birth*
Month
Day
Year
Age*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone*
Cell Phone
Email
Language*
- English
- Spanish
Marital Status*
- Never Married
- Married
- Partnered
- Widowed
- Divorced

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Appointment Reminder
How would you like your appointment reminder?*
Reminders are sent 48 Hours prior to scheduled appointments
Would you prefer..
- Voicemail
- Text
Consent
I would like an additional appointment reminder sent via email.
Primary Care and Emergency Contacts
Primary Care Physician
Emergency Contact
Emergency Contact Phone
Relationship

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Primary Insurance
Name of Insurance Company
(Please note if plan is Medicaid)
Insured's Name
First Last
Insured’s Date of Birth
Month
Day
Year
Policy ID Number
Group Number
Secondary Insurance
Name of Insurance Company:
Insured's Name
First Last
Insured’s Date of Birth
Month
Day
Year
Secondary Policy ID Number
Secondary Group Number

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What is the main concern that you would like to discuss with the provider today?*
Please list anyone in your family that have been diagnosed with a mental health condition along with the diagnosis
Have you ever received any type of mental health services (including counseling or hospitalizations?) If so please list the provider seen and/or facility*
Current Medications (include over the counter medications/supplements; include dose, frequency taken and reason for the medication)
Allergies?
Pharmacy
Who referred you to our office?

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Assignment of Benefits and Statement of Financial Policy
I hereby assign all rights, title, and interest of my primary and secondary insurance to Philip Malinas M.D. & Associates for the treatment of my medical services.

Payment methods include cash, check and credit card. Payment plans can be arranged in advance.

Insurance Reimbursement: In the event you receive reimbursement from your insurance company for services rendered by Philip Malinas M.D. & Associates, that payment is due and payable to our office and should be immediately forwarded to us.

Insurance Deductible: Deductibles or co-pay’s are to be paid in full prior to services being rendered.

If you do not have insurance payment is due in full at the time of service.

Fee for returned checks: The fee for returned checks is $30. The fee may be added to your account and payment is required in full by cash or credit card.

Records requests: All records requests will need to be on a signed form. These records are available to the patient with a charge of .60 cents per page and require a minimum of 3 business days to be processed.

I authorize treatment of the patient named above and agree to pay all fees and charges promptly upon presentation thereof, unless credit arrangements are agreed upon in writing. In the event legal action should become necessary to collect on an unpaid balance due for psychiatric services rendered I agree to pay reasonable attorneys fees or other such costs as the court determines to be proper. If covered by an HMO, I understand that I cannot be seen until the required authorization has been obtained. I also agree to pay all expenses that are not authorized or covered by my HMO. It is agreed that payments will not be delayed or withheld because of any insurance coverage issues or pending claims, and that all proceeds of insurance are assigned to this office where applicable. A copy of this assignment is as valid as the original.
Signature*
Date*
MM slash DD slash YYYY

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Policy on Missed Appointments and Cancelations
The responsibility to attend your appointment is yours:
To cancel or reschedule an appointment you must call our office and speak to someone or leave a message a MINIMUM of 24 hours before your scheduled appointment time. Patients that miss an appointment with out giving the required notice will be charged a fee ranging from $75.00 to $175.00 depending on the length of the appointment; this must be paid before a new appointment is scheduled, medications refilled, or medical records are released. TWO missed new patient appointments will result in not being accepted as a patient in our practice. Three missed appointments with our office as an established patient may result in the patient being discharged from our practice.

Medicaid will not allow for a no show or late fee to be applied to the patients account. These patients will be FILL IN ONLY and must call daily to get back on our schedule. They WILL NOT be scheduled for their next appointment.
Signature*
Date*
MM slash DD slash YYYY

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New Patient consent to the Use and Disclosure of Protected Health Information, Payment, or Health Care Operations for Philip Malinas M.D. & Associates, PLLC
I understand that as part of my healthcare Philip Malinas M.D. & Associates originates and maintains paper and electronic records describing my health, symptoms, examinations, test results, diagnosis, treatment and any plans for future care or treatment, Further more I understand that Philip Malinas M.D. & Associates will access any available electronic prescription history. I also agree to submit to an oral drug screening as my provider deems necessary. I Understand that this information serves as:
- A source of information for applying my diagnosis and treatment information to my bill
- A means by which a third party payer can verify that services billed were actually provided
- A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals
- A basis for planning my care and treatment
- A means of communication among many healthcare professionals who contribute to my care (to include electronic communication with your pharmacy and obtain prior authorizations from insurance companies)
I understand and have been provided with access to the Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
- The right to review the notice prior to signing this consent
- The right to object to the use of my health information for directory purposes, marketing, or fundraising
- The right to request restrictions as to how my health information may be used
I understand that Philip Malinas M.D. & Associates will agree to the restrictions requested. I understand that I may revoke this authorization in writing, except to the extent the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me.

I further understand that Philip Malinas M.D. & Associates reserves the right to change their notice. Should the organization choose to change their notice, a current notice will be available, and I may request a current copy at any time.

To request any restriction, it must be submitted in writing to the office manager.

I understand that as part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax and/or email. I fully understand the terms of this consent. Please accept or deny these terms below.
Use and Disclosure Consent*
- Accept
- Deny
Signature
Date
MM slash DD slash YYYY

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Communication with Family Members Policy
I authorize the following family members access to my medical records and financial information. I understand these persons can contact Philip Malinas M.D. & Associates on my behalf.
Name / Relationship
Name / Relationship
Name / Relationship
This information may include personal, psychological, medical, social, educational, clinical and/or professional information regarding the patient above.
Unless otherwise revoked, this authorization will expire on the following date, event, or condition:

If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from the date signed.
If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from the date signed.
Signature of Responsible Party/Patient:
Date
MM slash DD slash YYYY

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Medication and Controlled Substance Agreement & Information
- Medication must be used as prescribed and directed unless discussed with your provider. It is life threatening to chew or take a partial tablet of a long acting medication. Increasing your dose without close supervision of your provider could lead to drug overdose, causing severe sedation, respiratory depression and death.
- If you have a reaction to your medication DO NOT FLUSH IT OR THROW IT AWAY. You may be required to bring the remainder to the office to replace with a new prescription.
- Per the Board of Medical Examiners Regulations, Sec. 1 Chapter 630 and our office policy, controlled substance medications are to be obtained from only one provider.
- You should discuss any medication changes with your provider at your appointments and inform them of any new medication allergies.
- Allow for 3 WORKING DAYS for preparation of all refill prescriptions. If someone is to pick up a written prescription for you, they must be on your HIPAA release.
- • Please check with pharmacy to see if they have a NEW prescription on file (even if the medication bottle has 0 refills) as our electronic prescriptions are filed that way.
- Lost, stolen or misplaced prescriptions or medications may not be replaced. Early requests for refills will not be provided unless you have called and discussed this prior to running out of medication. Selling medication or sharing medication with family, friends, or any other person is illegal and will not be tolerated. You should protect and care for your medication as you would any extremely valuable possession. If you run out of your medication, either because of poor planning or because of taking in excess of what was prescribed, you are responsible for the consequences, including poor pain control and any withdrawal symptoms.
- Notify your provider if you are pregnant.
- The use of alcohol or recreational drugs while on opioids or other controlled substances is not allowed. Our office will not provide medications under these circumstances.
- • Philip Malinas M.D. & Associates reserves the right to Drug Screen ALL patient randomly to ensure medication compliance. Failure to provide at sample the time it is requested could result in termination from the practice and no further medications to be ordered.
Strict Compliance to this agreement is REQUIRED
Signature*
Date*
MM slash DD slash YYYY

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Consent
- I consent to the release of information created within 12 months before/after the date this authorization was signed
I understand that by choosing "Full Medical Record", records that are released or obtained my include up to, but not limited to, psychological, psychiatric, or other mental impairments or treatment, including psychotherapy notes, dug abuse, alcoholism , or other substance abuse, records with may indicate the presence of communicable or noncommunicable diseases, and/or tests for, or record of, HIV/AIDS, and gene-related impairments, including genetic testing results. I understand that the clinic will not condition treatment on my signing this authorization. The clinic will not deny me treatment if I do not wish to sign this form. I may refuse to sign this authorization form. I understand that I may revoke this authorization at any time, unless the disclosing party has already relied on my authorization to disclose health information. To revoke my authorization, I must submit a written request to Dr. Philip Malinas & Associates. Unless I revoke this authorization earlier, it will expire one year from the date of signature. I understand that if this information is disclosed to a third party, the information may no longer be protected by the federal privacy regulations and may be re-disclosed by the person/organization that receives the information. I understand the matters discussed on this form. I release the provider, its employees, officers, and directors, medical staff members and business associated from any legal responsibility or liability for the disclosure of the above information to the extent indicated and authorized herein.
Signature
Date
MM slash DD slash YYYY
If you are not the patient, but are signing on behalf of the patient, please complete the following:
Signature
Date
MM slash DD slash YYYY
Name
First Last
Relationship to Patient
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Step 1 of 13

Personal Information

Appointment Reminder

Primary Care and Emergency Contacts

Primary Insurance

Secondary Insurance

Guardian or Account Guarantor:

Medical History

Assignment of Benefits and Statement of Financial Policy

Policy on Missed Appointments and Cancelations

New Patient consent to the Use and Disclosure of Protected Health Information, Payment, or Health Care Operations for Philip Malinas M.D. & Associates, PLLC

Communication with Family Members Policy

Medication and Controlled Substance Agreement & Information

Mood Questionnaire

Please answer the following questions

Medical Records

We Welcome Your
questions & Comments

Step 1 of 13

Personal Information

Appointment Reminder

Primary Care and Emergency Contacts

Primary Insurance

Secondary Insurance

Guardian or Account Guarantor:

Medical History

Assignment of Benefits and Statement of Financial Policy

Policy on Missed Appointments and Cancelations

New Patient consent to the Use and Disclosure of Protected Health Information, Payment, or Health Care Operations for Philip Malinas M.D. & Associates, PLLC

Communication with Family Members Policy

Medication and Controlled Substance Agreement & Information

Mood Questionnaire

Please answer the following questions

Medical Records

We Welcome Your questions & Comments

We Welcome Your
questions & Comments