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Welcome to Dr. Saks' Office
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Forms to read and complete before first visit:

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Today’s Date ___/___/___

Bonnie R. Saks M.D. & Associates, LCC

REGISTRATION FORM

(please print)

 

­­­­­­­­­­­­­PATIENT INFORMATION

Last Name:                               First:                             M.I.:

Marital Status (circle one):

Single / Mar / Div / Sep / Wid

Is this your legal name?

 __Yes __No

If not, what is your legal name?

Sex _F __M _T

Birth Date:

Age:

Street Address:                                                                    City:                       State:                Zip Code:

Social Security No.:

Mobile Number:             

Home Number:

Work Number:

Employer:

Referred to Practice by (please check all that apply):

__Dr.____________       __Hospital   __Family  __ Friend  __ Close to home/work   __Phone Book  __Internet

Can messages be left on the phone numbers listed above? If not, please indicate:

                   

 

INSURANCE INFORMATION*

*Dr. Bonnie Saks is not contracted with any insurance companies therefore she is strictly self pay. Insurance information may be           needed in the future for Labs and other tests that may need to be performed.

Please indicate primary insurance:

__Aetna __BC/BS  __Cigna __Humana __Medicare __Tricare, Standard or Prime? __United Healthcare

__Value Options __Other_______________

Subscriber’s Name:

 

Subscriber’s S.S. No.:

Birth Date:

Group No.:

Policy No.:

Patient’s Relationship to Subscriber:

__ Self  __Spouse  __Child  __Other __________________

 

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IN CASE OF EMERGENCY

Name of Friend or Relative:

Relationship to Pt.:

Mobile Number:

Home Number:

 

 

­­­­­

The above information is true to the best of my knowledge. I give my consent for Dr. Bonnie Saks M.D. & Associates to provide treatment using psychotherapy and or medication.

 

__________________________________________                                                                                              _______________               

Patient/Guardian Signature                                                                                                      Date

PATIENT’S PRESENTING PROBLEM

 

What brings you to the office?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

How has this affected your family or job?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Have there been any legal issues? ____Yes ____ No. If yes, please explain:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Are you experiencing any of the following?

___ Weight gain. How much? _____

___ Weight loss. How much? _____

___ Changes in appetite

___ Sleep disturbances

___ Other _______________________________________________________________________________

 

 

Do you consider your general health to be: ___ Excellent ___Good ___Fair ___ Poor          

 

 

Please list your current medications:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Any allergies to medication? ___Yes ___No. If yes, please indicate: _________________________________

PAST PSYCHIATRIC TREATMENT

 

___None ___ Outpatient ___ Inpatient

 

Physician/Therapist:_______________________________________________________________________

 

Have you ever taken an anti-depressant/anti-anxiety medication before? ___Yes ___No.

If yes, please indicate below.

Medication

Dosage

Effective?

Side Effects

 

 

 

 

 

 

 

 

 

 

 

 

 

Was psychological testing done? ___Yes ___No.  If so, when? _____________________________________

 

Pertinent Family History (Medical/Psychiatric):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Alcohol/Drug Use (Past or Present):

(please include amount, frequency, and the periods of past use)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Do you feel that your drug/alcohol use is causing problems for you or your family?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

PATIENT’S SOCIAL HISTORY

 

 

With whom do you live? ___________________________________________________________________

 

Relationship with significant others? ___Good ___Bad. Please explain:

________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________

 

 

To whom do you turn for support, and how do they help you?

________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________

 

Do you have a spiritual orientation or belief system? ___ Yes ___ No

 

Please indicate the types of treatment you are interested in receiving:

___ Individual              ___Couples Therapy              ___Medication Management              ___Group Therapy

___ Sex Therapy               ___Psychological Testing

 

 

CANCELLATION AND NO-SHOW POLICY

 

 

Please be advised that this office requires a 48 hour notice (business days) to cancel or reschedule your appointment. If you call or leave a message with less than 48 hour notice, we reserve the right to charge a $40 administrative fee.

 

I have read the above statement and agree to the Cancelation and No-Show policy of Dr. Bonnie Saks M.D. & Associates.

 

Signature:_____________________________________                        Date:___________________

 

 

 

 

 

AUTHORIZATION TO RELEASE/OBTAIN INFORMATION

 

I, the undersigned patient, hereby give permission to Bonnie Saks M.D. & Associates of 3333 W. Kennedy Blvd. Suite 106, Tampa, Fl 33609, to release/obtain information including medical, psychiatric, psychological and substance abuse treatment contained in my medical records to the following person, agency or organization:

1._______________________________________________________________________________Phone:___________________________  Fax: ___________________________

2._______________________________________________________________________________

Phone: ___________________________ Fax: ___________________________

3._______________________________________________________________________________

Phone: ___________________________ Fax: ___________________________

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I acknowledge that I have read or have been given a copy of your Notice of Privacy Practices containing a more complete description of the uses of my health information. I understand that the office of Dr. Bonnie Saks M.D. & Associates has the right to change its Notice of Privacy Practices from time to time. I may contact this office at any time at the address above to obtain a current copy of the Notice of Privacy Practice. I understand that, under the Health Insurance Portability and Accountability Act if 1996 (“HIPPA”), I have certain rights of privacy regarding the protection of my health information. I understand that this information can and will be used to:

·         Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment, directly and/or indirectly.

·         Obtain payment from third-party payers

·         Conduct normal healthcare operations, such as quality assessments and physical certifications.

I understand that I may request in writing that this office restricts how my private information is used or disclosed to carry our treatment, payment or health care operations. I also understand that this office is not required to agree to my requested restrictions, but once agreed upon, this office is bound to abide by such restrictions.

 

Patient Signature:__________________________________________ Date: ___________________

OFFICIAL USE ONLY

I attempted to obtain the patients signature in acknowledgement of this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below:

Date:__________ Initials:_______ Reason:______________________________________________________________

 

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CARFULLY.

 

The Health Insurance Portability Accountability Act of 1996 (“HIPPA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, or paper, or orally, are kept properly confidential. This act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPPA” provides penalties for covered entities that misuse personal health information. As required by “HIPPA”, we offer this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes:

·         Treatment: Providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would be a psychological exam, the results of which are shared with primary care doctor. In the course of treatment, clinicians are obligated by law to report child abuse, elder abuse, and danger to self or others.

·         Payment: Such activities as obtaining reimbursements for services,  confirming coverage, billing or collections activities and utilization review. An example if this would be submitting a claim to your insurance company for payment.

·         Health Care Operations: Include the business aspect of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer services. An example would be medical review, legal services and auditing functions.

 

We may also create and distribute de-identified health information by removing all references to individuality identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorizations in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Office Manage (Privacy Officer):

·         The right to request restrictions on certain uses and disclosure of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

·         The right to reasonable request to receive confidential communications of protected health information from us by alternative means, or alternative locations.

·         The right to inspect and copy your protected health information.

·         The right to amend your protected health information.

·         The right to receive an accounting of disclosures of protected information.

·         The right to obtain a paper copy of this notice from us upon request.

 

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to your protected health information. We cannot be responsible for computer, cell phone or text message violation by unauthorized third party.

This notice is effective as of April 14th, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health and Human resources, Office of Civil Rights, about violations of the provisions if this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

 

For more information about HIPPA or to file a complaint:   The U.S. Department of Health Human Services

                                                                                                Office of Civil Rights

                                                                                                200 Independence Ave, S.W.

                                                                                                Washington, DC 20201

FINANCIAL POLICY

 

This is an agreement between Bonnie R. Saks, MD, as creditor, and the Patient/Debtor named on this form. In this agreement the words “you,” “your,” and “yours” mean the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words, “we,” “us,” and “our” refer to Bonnie R. Saks, MD and Associates LLC. By executing this agreement, you are agreeing to pay for all services that are received. 

 

Monthly Statement: If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, and any payments or credits applied to your account during the month. Unless other arrangements are approved by us in writing, the balance on your statement is due and payable when the statement is issued, and the past due if not paid by the end of 30 days.

Billing Information: You understand that is your responsibility to notify the office of any changes in address, phone number or insurance coverage, both primary and secondary.

Past Due Accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all of the collection costs which are incurred. If we have to refer collection of the balance to a lawyer, you agree to pay all lawyers’ fees, which we incur plus all court costs.

Waiver of Confidentiality: You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

Returned Checks: There is a fee (currently $37) for any checks returned by the bank. This amount is subject to change without prior notification.

Missed Appointment Fee: Patients who do not show up on time for an appointment, or cancel with less than 48 hours notice will be charged a $40 administrative fee. Patients with three missed appointments will be asked to transfer their records to another doctor.

Transferring Records: You will need to request in writing, and pay a reasonable copying fee (currently $1 for the first 25 pages, ₵25 thereafter) if you want to have copies of your records sent to another doctor or organization. This fee will be waived if records are being sent to your primary care physician (PCP). You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history.

Co-Signature: If this or another Financial Policy is signed by another person, that co-signature remains in effect until cancelled in writing. If written cancellation is received, it becomes effective with any subsequent charges.

Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.

Patients should be aware that any medications prescribed have potential risk.

Patients Name: ___________________________________________________________________________

Responsible Party: ________________________________________________________________________

(If not the patient)

 

Signature:____________________________________________________________ Date:_______________

 

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