Personal Health History (check all that apply)

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)

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.

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 to $100 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.

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.

AcceptDeny

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.

• 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

Name *

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Patient's Name *

Name

Relationship to Patient