New PT paperwork

Marital Status

• -  Single __

• -  Married __

• -  Domestic Partner __

• -  Separated ___

• -  Divorced ___

• -  Widowed-____

   

  0. Address:

  Street Address: ___________________________________________________

  Apt./Unit #: City:

  Mobile Phone:

  __________________________ __________________________ State: ______

   _________________________
  

  Zip Code: ______

  Email: ________________________________ Preferred contact method:

  Mobile Phone Home Phone Work Phone Email

   ______
   _______
  

  ______
   ______
  

  Social Security Number__________________________

   

  Employer __________________________ Occupation _________________________
  Drivers License Number ______________________

  BENEFITS INFORMATION

  Although we do not participate with any Insurance companies we still need your insurance information for possible future medication pre-authorization . Please attach a copy of the front and back of your insurance card to this form. Please bring your actual insurance card to your next appointment for a more clear copy.
  Your assistance in providing accurate and prompt return of those forms is essential in allowing our team to work on prior authorizations .

  Primary Insurance ____________________
  Primary Insurance Company _______________________________ Member ID / Policy # _____________________________________ Group Number __________________________________________ Client Relationship to Insured

  Self_____ Spouse_____ Child_____ Other_____

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  Insured Name ____________________

  Insured Date of Birth__/___/______

  Insured Phone ____________________

  Insured Street Address ____________________ City ____________________State____ Zip___ .

  Sec Insurance ________________________________________________________ _______________________________________________________________________

  Please attach a photo of your insurance card. (front and back)

  Please attach a current photo ID/ DL card
  I authorize the release of any medical information necessary to process medication prior authorizations .

  PATIENT MEDICAL HISTORY

  DATE: _____________________
  PATIENT NAME:______________________________________
  REASON FOR YOUR VISIT TODAY: ___________________________________

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  MEDICAL ALLERGIES:_________________________________________________________________________________

  ___________________
  

  PAST/CURRENT MEDICAL DIAGNOSES: ____________________________________________________________________________________________ ____________________________
  OUTPATIENT PSYCHIATRIC TREATMENT/DIAGNOSIS HISTORY:

  ____________________________________________________________________________________________ ____________________________
  PSYCHIATRIC/MEDICAL HOSPITALIZATIONS & RELATED DIAGNOSIS: ____________________________________________________________________________________________ ____________________________

  DO YOU SMOKE? Y/ N HOW MUCH? ___________ DRINK ALCOHOL? Y/N HOW MUCH?___________ DO YOU USE RECREATIONAL DRUGS? Y/N
  HOW OFTEN ? HOW MUCH?_____________________ NAME OF DRUGS:____________________________-

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  CHECK ALL THAT APPLY

  HIGH BLOOD PRESSURE		DIABETES		HIGH CHOLESTEROL
  BLURRED VISION		LOSS OF VISION		CHEST PAIN
  WEIGHT LOSS/GAIN		NAUSEA/VOMITTING		HOT FLASHES
  STROKE		SHORTNESS OF BREATH		BACK PAIN
  ASTHMA		JOINT PAIN		INSOMNIA
  LOW/HIGH THYROID		CONSTIPATION		CANCER
  DIARRHEA		HEADACHE		URINARY PROBLEMS
  ACID REFLUX		FATIGUE		MEMORY LOSS

  OTHER (PLEASE SPECIFY): __________________________________________________________________________

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  FAMILY HISTORY

  	yes	No	RELATION
  BIPOLAR DISEASE
  DEPRESSION
  SCHIZOPHRENIA
  ATTEMPTED SUICIDE
  SUBSTANCE ABUSE?
  DEMENTIA

  Please list all medications, supplements, or herbs taken currently along with psychiatric medications/supplements/herbs
  taken in the past. If you need more room, please print and attach.

  Dates:________-________ Medication:_________________________ Dose:__________ Effective? Y N Side-effects?: Y N
  Dates:________-________ Medication:_________________________ Dose:__________

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  Effective? Y N Side-effects?: Y N
  Dates:________-________ Medication:_________________________ Dose:__________ Effective? Y N Side-effects?: Y N
  Dates:________-________ Medication:_________________________ Dose:__________ Effective? Y N Side-effects?: Y N

  Name ___________________ Signature ___________________ Date ________________

  ________________________________________________________________________________
  

  PROFESSIONAL SERVICES/BUSINESS POLICIES

  Please be sure to read the Privacy Policies, Consent for Treatment and Authorization to Release Information carefully. These forms give details regarding our responsibilities to you as well as your agreement for proceeding with treatment.

  PRIVACY POLICIES

  This notice describes how medical information about you may be used and disclosed and your access to

  it. Protected health information about you is obtained as a record of your visits or contacts with the

  providers and staff for healthcare services. Specifically, PROTECTED HEALTH INFORMATION is

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  information about you, including demographic information (name, address, age, etc.) that may identify you and may relate to your past, present and/or future physical or mental health condition(s) and related healthcare services.

  The Institute for Advanced Psychiatry is required to follow specific rules for maintaining the confidentiality of your protected health information, the use of your information and how this information is disclosed or shared to/with other healthcare professionals involved in your care and treatment. This Policy describes your rights to access and control your protected health information. It also describes how we follow those rules in the use and disclosure of your protected health information for the purposes of providing treatment, obtaining payment for the services you receive, managing our healthcare operations and for other purposes permitted/required by law.

  YOUR RIGHTS UNDER THE PRIVACY RULE

  The following is a statement of your rights under the Privacy Rule in reference to your protected health information. Please feel free to discuss any questions/concerns with the staff.

  RIGHTS TO A COPY OF PRIVACY POLICIES

  We are required to follow the terms of this notice. We reserve the right to change the terms of our notice at any time. If needed, new versions of this notice will be effective for all protected health information that we maintain. Upon request, you will be provided with a revised Notice of Privacy Policies.

  YOUR RIGHTS TO AUTHORIZE OTHER USE AND DISCLOSURE

  This means that you have the right to authorize or deny authorization for any other use/disclosure of protected health information not specified in this notice. You may revoke an authorization at any time except to the extent that the Institute for Advanced Psychiatry staff has taken an action in reliance on the use or disclosure indicated in the authorization. Any revocation of authorization to use or disclose protected health information must be presented in writing.

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  YOUR RIGHTS TO DESIGNATE A PERSONAL REPRESENTATIVE

  This means that you may designate a person who then has the delegated authority to consent to or authorize the use or disclosure of your protected health information. Any notice of revocation of authorization/designation of a previously named personal representative must be presented in writing.

  YOUR RIGHTS TO YOUR PROTECTED HEALTH INFORMATION

  This means that you may inspect and obtain a copy of protected health information about you that is contained in your patient record. Under certain circumstances, we may deny your request. Any requests for copies of your protected health information must be made in writing.

  YOUR RIGHTS TO REQUEST A RESTRICTION OF YOUR PROTECTED HEALTH INFORMATION

  This means that you may request, in writing, that we not disclose any part of your protected health information for the purposes of treatment, payment for service you have received, or healthcare operations. You may also request that any part of your protected health information be restricted from disclosure to others who may be involved in your care or for notification purposes as described in this Notice of Privacy Policies. Under certain circumstances, we may deny your request for restriction. All requests for restriction of your protected health information must be made in writing.

  YOUR RIGHTS TO REQUEST YOUR PROTECTED HEALTH INFORMATION AMENDED

  This means that you may request an amendment of your protected health information for as long as we maintain the information. Under certain circumstances, we may deny your request for an amendment. All requests for amendment to your protected health information must be made in writing.

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  PRIVACY POLICY AUTHORIZATION

  You have certain rights regarding your protected health information under the Health Insurance Portability and Accountability Act (HIPPA). This document allows you to specify under what conditions your protected health information may be used or disclosed. HIPAA gives individuals the right to request restrictions on uses and disclosures of their protected health information (PHI).

  The Institute for Advanced Psychiatry reserves the right to change notices and practices and that I will be given new notification, upon request, if this occurs. I understand that I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment or healthcare operations.

  The Institute for Advanced Psychiatry may release any/all medical information needed to my insurance company .

  I understand that I may revoke this consent in writing, except to the extent that the providers of the Institute for Advanced Psychiatry and support staff have already taken action in reliance thereon. I also understand that Dr. Diana Ghelber, MD or another appropriate provider designated for your care, and the support staff are not required to adhere to the restrictions requested in the event of a potentially life-threatening emergency

  The Institute for Advanced Psychiatry may release protected health information to HIPAA covered entities on my behalf. This includes, but is not limited to, health/insurance plans, other healthcare providers, healthcare claims clearinghouses and others.

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  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  I understand that I am also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to your office instead of your home. The Institute for Advanced Psychiatry staff may contact me in the ways specified below for general information (Mark appropriate option):

  Cell ____ Home phone___ work phone___ Email___ SMS______

  The Institute for Advanced Psychiatry staff may communicate verbally and/or via email with others (including but not limited to family members who may answer the phone/check email) regarding appointments, test results and other general information.

  List all approved persons who can receive information on your behalf: Name and Cell______________________
  Name and Cell_______________________
  Name and Cell_____________________

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  I understand this release may include records that contain information regarding the diagnosis and/or treatment of HIV or AIDS, mental illness and/or drug and/or alcohol addiction or abuse to any person or corporation which is or may be liable under contract for all or part of the medical charges, including but not limited to Medicare, Medicaid or other private or public health insurance programs, reviewing agencies, worker’s compensation carriers, welfare agencies or the patient’s employer. (The patient’s employer will only be contacted if necessary to confirm enrollment in a healthcare plan).

  I consent to receive appointment reminders in the ways specified below (Mark appropriate option):

  Cell Phone ____ VM ___ SMS ____ Email
  I consent to receive receipts in the ways specified below

  (Mark appropriate option):
  Email ____ In-Person _____
  I consent to receive Laboratory Requisite in the ways specified below

  Email __ In Person ___

  MY SIGNATURE BELOW SIGNIFIES THAT I HAVE READ, UNDERSTOOD AND RECEIVED A COPY OF THE NOTICE OF PRIVACY POLICIES. IN ADDITION I UNDERSTAND THAT THE ABOVE AUTHORIZATIONS MAY BE REVOKED AT ANY TIME BY WRITTEN NOTICE TO THE INSTITUTE FOR ADVANCED PSYCHIATRY . ANY REVOCATION WILL BECOME EFFECTIVE ON

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  THE DATE IT IS RECEIVED BY THE OFFICE OF THE INSTITUTE FOR ADVANCED PSYCHIATRY. I UNDERSTAND THAT THIS AUTHORIZATION DOES NOT LIMIT THE TREATMENTS AVAILABLE TO ME; IT ONLY AFFECTS THE USE OF MY PROTECTED HEALTH INFORMATION. I ACKNOWLEDGE AND UNDERSTAND THAT USES AND/OR DISCLOSURES OF MY PROTECTED HEALTH INFORMATION BY HIPAA COVERED ENTITIES RECEIVING INFORMATION MAY OCCUR AND UNDER THESE CIRCUMSTANCES, I ABSOLVE DR. DIANA GHELBER MD, PA AND MEMBERS OF HER STAFF OF ANY RESPONSIBILITY AND/OR LIABILITY FOR SUCH USE AND/OR DISCLOSURE.

  GENERAL OFFICE POLICIES AND REGULATIONS

  The following are the policies and regulations of this office and are followed without exception. Read them carefully. Signing below indicates that you have been made aware of them and that you agree to adhere to them. If you are a minor, parent or guardian signature is required.

  CONSENT FOR TREATMENT I, the undersigned, as the patient or on behalf of the patient do hereby consent to and authorize all diagnostic and therapeutic plans considered necessary or advised in the judgment of the physician . I understand that no guarantee or assurance has been made as to the results, which may be obtained.

  APPOINTMENTS Services are by appointment only. In the event of an emergency, we will try to work you in. This may cause a wait and we ask for your patience in this regard. As a courtesy, we provide a reminder call , 2 reminder emails; and /or text messages, however, it is your responsibility to be aware of your appointment date and time and to show up on time for that appointment whether or not you receive a confirmation call/email. We recommend that you show up early for your appointment and anticipate traffic, weather conditions, etc. If you arrive late, we will not be able to give you additional time as your allotted time has been pre-scheduled and reserved for you. Arriving late for an appointment may not allow

  sufficient time for you to address any issues/concerns you wish to discuss with the clinician/technician.

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  CANCELLATIONS: In an effort to provide excellent service to all of our clients/patients in the best therapeutic environment, it is our policy to require a fee for no-show appointments and cancellations made less than 24 hours in advance of the scheduled appointment. The cancellation fee must be paid before my next scheduled appointment. If you have missed an appointment you will not be given another nor have your medications refilled until you have paid the missed appointment fee.

  • A fee of $100 will be assessed for missed/late-cancelled follow-up appointments

  • A fee of $100 will be paid before rescheduling a missed/late-cancelled initial evaluation appointment

  REQUESTS FOR MEDICAL RECORDS If you have an appointment with another provider or any other request that requires information, referrals and/or medical records , you must notify our office at least 7 business days prior to your appointment date. All information in your chart is strictly confidential and cannot be released to anyone without your written consent. Records can be transferred to another physician upon your written request. This usually takes up to thirty days and is done in the order in which their requests are received. Records transferred to any persons other than physicians, i.e., patients, lawyers, certain insurance companies, etc. are subject to a fee. The amount of this fee will depend on the volume of the record.

  LETTERS/ ADDITIONAL PAPERWORK REQUESTS The time taken to review and/or process patient paperwork (extensive medical records, reports, correspondence, chart notes, etc.) will be assessed a fee for the time spent on the paperwork. All letters to any person other than physicians will be subject to a fee starting from $80.00. Again, the exact amount will depend on the complexity of the document and time spent. by the provider Patients are expected to pay for all requested papers before they can be sent or picked up. An authorization to release healthcare records will be required before paperwork can be completed. Please allow 10 business days to complete any requested paperwork. Our office does not do paperwork regarding disability or court appointed paperwork.

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  BILLING/ CLAIMS The Institute for Advanced Psychiatry is NOT contracted with insurance companies, and we do not file claims for the services you receive. We will provide receipts containing procedure and diagnosis codes upon request. Receipts requested at the end of the year will incur a fee based on time and resources spent.

  PAYMENT POLICY/ FEE AGREEMENT The Institute for Advanced Psychiatry requires payment for services at the time they are rendered. If payment is not rendered at time of service you will not receive service. You will also be responsible for the $100 fee. Payments may be made with cash, personal check or credit card. We do NOT take American Express. There will be a $50 additional fee for all returned checks. If you have any questions regarding payment and services you need to address this at time of service or no refund will be given. No refund will be given for rendered services. Patients are expected to maintain a zero balance. Accounts need to remain current in order to maintain ongoing treatment. Our office does not send patients invoices, but statements are available after each procedure. Please feel free to inquire about your balance before your account becomes delinquent. The patient/guardian is responsible for court costs, legal fees, or agency fees, which may be incurred in the collection of the account.

  COURT FEES: If a deposition or opinion in court is required there is $750 per hour charge, with a minimum charge of $2500 which must be paid in advance. IF Dr. Ghelber or designated provider is subpoenaed with less than 15 days notice is subject to an extra $2500 charge. We require a phone call from the patient or lawyer to notify the office

  PHONE CONFERENCES Patients are charged for time spent consulting with the providers on the telephone or the time taken for the clinician to consult with other professionals regarding your treatment (with your permission). The fee charged depends on the length of the conference.

  PATIENT RIGHTS At any time, patients may question and/or refuse therapeutic or diagnostic procedures or methods, or gain whatever information they wish to know about the process and course of therapy. Patients are also assured confidentiality that is protected both ethically by the Institute and legally by

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  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  Texas State Law. There are, however, important exceptions to confidentiality that are legally mandated. In general terms, these exceptions include the following: 1) The law requires notification of relevant others if it is judged that a patient has an intention to harm him/ herself or another individual. 2) The law obliges us to report any incident of suspected child abuse, neglect or molestation in order to protect the children involved. Confidentiality will be respected in all cases, except as noted above.

  DEPENDENT PATIENTS If you are requesting our services as the parent/guardian of a child under the age of 18 or as the guardian of a dependent adult, the same general practice as outlined above will apply. However, as the child or dependent adult’s psychiatric care provider, it is important that the patient be able to trust the physician/technician. As such, the physician/technician will keep the content of the patient’s sessions confidential in the same way that she would keep confidential the content of an independent adult patient’s sessions. This is not only the clinic policy, but also a state and federal law. This is true even when the parent/guardian is financially responsible for the patient’s appointments. In general, specific information that the patient provides will not be released, however it is appropriate to discuss with the parent/guardian, the patient’s progress and the parent/guardian participation in their treatment and any issues that represent imminent safety concerns.

  MESSAGES The Institute for Advanced Psychiatry has regular business hours Monday- Thursday 8am-4pm and Friday 8am-3pm . During this time, messages may be left for clinician with any of the office staff.

  At any time: -FOR LIFE THREATENING EMERGENCIES YOU MUST CALL 911 OR PROCEED TO YOUR NEAREST EMERGENCY ROOM.

  THESE SITUATIONS SHOULD NOT BE HANDLED BY LEAVING A VOICEMAIL, EMAIL, PATIENT PORTAL OR A MESSAGE FOR THE DOCTOR.

  For URGENT MATTERS, which cannot wait until the next business day, you may call the office phone at

  817.659.7344 and leave a voicemail or call the doctor on call. If you need to speak with Dr. Ghelber

  Monday-Thursday after normal business hours you may call the office and dial 8. A fee of $75 will be

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  assessed. On the weekends, you may contact the doctor on call whose contact information will be on the office line voicemail message. For all other matters, please call the clinic during normal business hours. Often, one of the office staff can handle your question and they will be pleased to assist you. Although your message is very important to us, please know that leaving multiple messages or emails will not speed up the process to receive a returned call. We check voicemails and emails periodically throughout the day and will contact you at our earliest convenience or, at the most, by the end of the business day.

  Our clinical practitioners do not discuss medication questions, psychotherapy issues, or personal matters via email. These matters are best discussed in an appointment . Any emails you send to clinicians may be read by office staff, so email communication should only be used for scheduling purposes.

  MEDICATION REFILLS/ AFTER HOUR No routine prescriptions will be refilled after hours or on the weekends. Check your medications regularly and make sure that you have enough. Please allow 72 hours for the prescription refill request to be processed. All requests received after 4pm on Thursday may not be processed until Monday. If you miss your appointment or run out of medication because you did not schedule a timely follow-up appointment as agreed upon in the previous appointment, prescriptions will, in general, not be refilled until you have a scheduled appointment. No refills will be allowed after repeated cancelations or if not clinically appropriately. Due to administrative requirements on issuing CII prescriptions a fee of 25 dollars will be implemented for requests between office visits . Be sure to notify your provider if you are pregnant or think you may be pregnant. If you become pregnant while taking psychiatric medication(s), you will need to discuss the risks and benefits of the particular treatment(s) you are on with the clinician. In the case of an emergency please follow the protocol listed above.

  COURTESY We believe that it is important to make everyone as comfortable as possible when visiting

  the Institute for Advanced Psychiatry. We ask that you put any mobile devices on silent and refrain from

  using them during your session. Should you need to take or make a telephone call while waiting, please

  step outside to avoid disturbing others. In addition, we try to create an environment of courtesy and

  respect for patients, physicians and staff. Please remember to be courteous to everyone while present in

  the clinic. Rude or disruptive behavior could result in termination of the physician-patient relationship.

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  Every effort is made to begin appointments on time, but sometimes it may be necessary to wait. We appreciate your patience and understanding.

  TERMINATION At times, terminating the physician-patient relationship is necessary. Termination of psychiatric treatment may occur at any time and may be initiated by either the patient or the doctor. Reasons for termination by the physician are generally due to patient non- compliance with treatment(s), missed appointments, multiple cancellations, or, in rare cases, the inability to continue a therapeutic relationship. The Institute for Advanced Psychiatry will continue to provide your care for 30 days after a notice of termination in order to allow you to find a new physician.

  INACTIVE STATUS The patient will only be considered an active patient if the patient keeps each appointment made or makes an alternative appointment with the office. After the passage of six months without an appointment the patient will automatically be considered an inactive .

  Inactive status may be instituted if bills are not paid in a timely fashion. Inactive status may be Institute after two appointments missed with less than 24 hour cancellation notice.

  Inactive status designates that The Institute for Advanced Psychiatry will reserve the right to direct triage to another provider or facility if the need arises. Only emergency triage will be provided. If the doctor has prescribed medication continuously and inactive status starts, a maximum of one month of medication may be prescribed while the patient finds an alternative health care provider. If the doctor decides to reinstate you as an active patient, a new patient appointment will be required.

  Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites. 1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit. 2. I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room. 3.I attest that I understand that I have to be physically in Texas for my appointment and I will comply with

  this requirement 4. I understand that there are potential risks to using technology, including service

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  interruptions, interception, and technical difficulties. a. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my healthcare provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit. 5. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services. 6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes. a. I understand that my insurance carrier will have access to my medical records for quality review/audit. b. I understand that I will be responsible for any out-of-pocket costs that apply to my telemedicine visit. c. I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits. 7. I understand that this document will become a part of my medical record. By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language.

  We trust that you understand the necessity for these terms, and we thank you for your cooperation. If you have any questions, do not hesitate to ask the staff or the doctor.

  Please sign below, acknowledging that you have received the above information and agree to abide by the terms hereof;

  MY SIGNATURE BELOW CERTIFIES THAT I HAVE READ AND UNDERSTOOD THE ABOVE STATED GENERAL OFFICE POLICIES AND REGULATIONS OF THE INSTITUTE FOR ADVANCED PSYCHIATRY.

  NAME ___________________ SIGNATURE ____________ Date ______________

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  Agreement for Control Substance Treatment

  This agreement has been developed in the interest of promoting optimal drug therapy while minimizing risks to the patient. Your compliance is appreciated

  I, *______________________
  agree that Dr. Diana Ghelber/or another appropriate provider designated for your care will be the

  only clinician prescribing medication for benzodiazepines or ADHD medication

  1. I understand the importance of taking the medication at the dose and frequency prescribed by my physician.

  2. I will attend all reasonable appointments, treatments and consultations as requested by my physician.

  3. Refills:- Controlled substance prescriptions are highly controlled and followed by the State of Texas. Due to administrative requirements on issuing controlled substance prescriptions, a fee of 25 dollars will be implemented for requests between office visits.

  - The medication will not be refilled after hours and on weekends.

  Check your medication regularly. Make sure that you have enough. Allow 72 hours for the refill to be processed. Requests received Friday after 12.00 pm may not be processed until Monday.

  - It is the responsibility of the patient to ensure the correct pharmacy is on file. It is the responsibility of the patient to ensure pharmacy on file has adequate stock of medication

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  - Be aware, that stopping Benzodiazepines abruptly in certain doses, has been associated with risk of seizures. You will need to present to the Emergency Room to have the prescription renewed until our clinic is during regular business hours.

  4. Benzodiazepines can not be prescribed with opiates due to risk of respiratory depression and death. Please update all your providers of any change in your medication.

  5. You must agree that early refills will not be given. The prescribing physician may require random urine testing as a matter of routine monitoring. 


  6. I agree to be responsible for the secure storage of my medication at all times. I understand the importance of not informing others about my Benzodiazepines/stimulant therapy. I acknowledge that my physician is not obligated to replace any medication shortfall.

  7. I agree that medications will not be replaced if they are lost, flushed down the toilet, destroyed, left on an airplane, etc.

  If your medication has been stolen, you will need to complete a police report regarding the theft and present that report to the prescribing physician.

  8. I understand that is illegal to share , sell my medication, to use someone else medication, or to use multiple prescribers for my medication

  I understand that if I break this agreement, my physician reserves the right to stop prescribing stimulant medications for me. 


  Date: __/__/ ____ Signature – Patient ___________________________

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  MEDICARE PRIVATE CONTRACT AUDRA COSTON This contract is entered into this date * __/ ___/___

  by Name _____________________

  and between AUDRA COSTON , NP (hereinafter called “ nurse practitioner ), whose principal medical office is located at 6800 Harris Parkway suite 100 and suite 100B FW, Tx (hereinafter called “beneficiary”), and shall become effective on DECEMBER 18, 2024 Nurse practitioner Obligations

  The nurse practitioner has informed the patient that the nurse practitioner has opted out of the Medicare program effective on DECEMBER 18, 2024 for a period of at least two years. Physician acknowledges that she is not excluded from Medicare part B under sections 1128, 1156, 1892 or any other section of the Social Security Act.

  The nurse practitioner acknowledges that this contract shall not be entered into with the beneficiary, or the beneficiary's legal representative, during a time when the beneficiary requires emergency care services or urgent care services, except that the physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440.

  The nurse practitioner acknowledges that she must retain this contract (with original signatures of both parties to this contract) for the duration of the opt-out period, and that it shall be made available to the Centers for Medicare and Medicaid Services (CMS) upon request.

  The nurse practitioner shall provide a copy of this contract to the beneficiary, or to his or her legal representative, before items or services have been furnished to the beneficiary under the terms of this contract.

  The nurse practitioner acknowledges that she must enter into a contract for each opt-out period

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  Beneficiary Obligations

  The beneficiary, or his or her legal representative, accepts full responsibility for payment of the nurse practitioner's charge for all services furnished by the physician.

  The beneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the nurse practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.

  The beneficiary, or his or her legal representative, understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physician.

  The beneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the nurse practitioner to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare.

  The beneficiary acknowledges that this written private contract contains sufficiently large print to ensure that the beneficiary is able to read this contract.

  The beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out.

  The beneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  The beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the physician during a time when the beneficiary requires emergency care services or urgent care services, except that the physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440.

  The beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the beneficiary, or to his or her legal representative, before items or services have been furnished to the beneficiary under the terms of this contract.

  Date _________________

  Signature ______________________

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  MEDICARE PRIVATE CONTRACT DR DIANA GHELBER This contract is entered into this date *___/___/_____

  by Name *_____________________
  and between Dr Diana Ghelber, MD (hereinafter called “physician”), whose principal

  medical office is located at 6800 Harris Parkway suite 100 and suite 100B FW, Tx (hereinafter called “beneficiary”), and shall become effective on this November 7th, 2019 Physician Obligations

  The Physician has informed Patient that Physician has opted out of the Medicare program effective on November 1 for a period of at least two years. Physician acknowledges that she is not excluded from Medicare part B under sections 1128, 1156, 1892 or any other section of the Social Security Act.

  The physician acknowledges that this contract shall not be entered into with the beneficiary, or the beneficiary's legal representative, during a time when the beneficiary requires emergency care services or urgent care services, except that the physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440.

  The physician acknowledges that she must retain this contract (with original signatures of both parties to this contract) for the duration of the opt-out period, and that it shall be made available to the Centers for Medicare and Medicaid Services (CMS) upon request.

  The physician shall provide a copy of this contract to the beneficiary, or to his or her legal representative, before items or services have been furnished to the beneficiary under the terms of this contract.

  The physician acknowledges that she must enter into a contract for each opt-out period

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  Beneficiary Obligations

  The beneficiary, or his or her legal representative, accepts full responsibility for payment of the physician's charge for all services furnished by the physician.

  The beneficiary, or his or her legal representative, understands that no payment will be provided by Medicare for items or services furnished by the physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.

  The beneficiary, or his or her legal representative, understands that Medicare limits do not apply to what the physician may charge for items or services furnished by the physician.

  The beneficiary, or his or her legal representative, agrees not to submit a claim, nor ask the physician to submit a claim, to Medicare for Medicare items or services, even if such items or services are otherwise covered by Medicare.

  The beneficiary acknowledges that this written private contract contains sufficiently large print to ensure that the beneficiary is able to read this contract.

  The beneficiary, or his or her legal representative, has entered into this contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare and for whom payment would be made by Medicare for their covered services, and that the beneficiary has not been compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out.

  The beneficiary, or his or her legal representative, understands that Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  The beneficiary, or his or her legal representative, understands that this agreement shall not be entered into with the physician during a time when the beneficiary requires emergency care services or urgent care services, except that the physician may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 42 C.F.R. § 405.440.

  The beneficiary, or his or her legal representative, acknowledges that a copy of this contract has been provided to the beneficiary, or to his or her legal representative, before items or services have been furnished to the beneficiary under the terms of this contract.

  Date __________________

  Name of Beneficiary (printed) or His/Her Legal Representative

  *________________________________

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249

   

   

   

   

  Transcranial Magnetic Stimulation, PRISM, Ketamine & Botox Therapy

  SELF-PAY AGREEMENT FOR CIGNA MEMBERS

  I, ____________________________, have been notified by my Participant Name

  provider/facility ___INSTITUTE FOR ADVANCED PSYCHIATRY _______________________ and/or Practitioner Name a CIGNA Behavioral Health representative _________N/A____________ CIGNA Behavioral Health Representative Name that my treatment is not a covered benefit under my benefit plan or that my treatment starting at ___________ is no longer covered by my benefit plan Date because CIGNA Behavioral Health had determined the treatment does not meet CIGNA Behavioral Health’s standards for medical necessity. I am aware of CIGNA Behavioral Health’s formal clinical appeal process and have elected not to appeal this decision at this time. Instead, I have chosen to continue treatment with my provider/facility on a self-pay basis starting ____________, which is no earlier than signature date. Date I understand that it is my responsibility to pay _____________________ for Amount ____________________________ and I will not be reimbursed by CIGNA Services Behavioral on a later appeal. I have been informed that I have the right to request an appeal at a later date. This Self-Pay Agreement applies only to the service listed above.

  If I move to another level of care, an authorization from CIGNA Behavioral Health must be obtained or another Self-Pay Agreement signed.

  Participant Signature ___________________________ Date __/__/ ______

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  6800 Harris Parkway, Suite 100, Fort Worth, TX 76132 www.psychiatryfortworth.com P 817.659.7344 F 888.501.5249