New Patient

Thank you for selecting our office for your psychiatric care. We will strive to provide you with the best possible care. To help us, please fill out this form completely in ink. If you have any questions or need assistance, please ask us. If you are a Medicare beneficiary or are Medicare eligible, please read this and sign the contract. We will be happy to help.


Personal Information

Patients Name___________________________________________________Date________

Wishes to be called___________________________________________________________

o Male o Female o Minor o Single o Married o Divorced o Widowed o Separated

Birthdate__________________________SSN_____________________________________

Address____________________________________________________________________

City, State, Zip ______________________________________________________________

Employer _____________________________Occupation ____________________________

Referred by _________________________________________________________________


Your Preferences for How We Contact You

Home Phone____________________________ Fax ________________________________

Work Phone_____________X_____

Cell Phone_____________________Where do you prefer to receive calls? o Home o Work o Cell

When is the best time to reach you? Time___________Days________________________

In the event of an emergency, whom should we contact?

Name______________________________Relationship_______________________________

Work Phone________________________Home Phone______________________________


Responsible Party

Who is responsible for the account?

Name______________________________________________________________________

Relationship to patient_________________________________________________________

Birthdate_____________________________SSN___________________________________

Address_____________________________________________________________________

City, State, Zip_______________________________________________________________

Employer____________________________________________________________________

Occupation__________________________________________________________________

Work Phone___________________X______Home Phone____________________________


Insurance Information

Primary Insurance

Name of Insured __________________________Relationship to patient__________________

Insured’s birth date ________________________ SSN_______________________________

Employer_______________________________Date Employed________________________

Occupation___________________________Employee/Cert.#__________________________

Insurance Company ________________________Group Number______________________

Ins. Co. Address_____________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Deductible________________ Amount already used ______________Annual benefit________

Additional Insurance

Name of Insured____________________________ Relationship to patient________________

Insured’s birth date__________________________SSN______________________________

Employer_______________________________ Date Employed________________________

Occupation____________________________________Employee/Cert.#_________________

Insurance Company ________________________Group Number______________________

Ins. Co. Address_____________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Deductible________________ Amount already used ______________Annual benefit________


Medical History

Please circle all that apply:

Diabetes | Anemia | Appendicitis | Pneumonia | Jaundice | Arthritis | Bone Disease | Joint Disease | Epilepsy | Hepatitis | Head Injury | Liver Disease | Gall Bladder Disease | Food Poisoning | Chemical Poisoning | Drug Poisoning | Bladder Disease | Tuberculosis | Migraine | Heart Disease | Ear Disease | Ear Injury | Colitis | Other Bowel Disease | Ulcer | Gastritis | Cancer | Hemorrhoids | Eye Disease | Eye Injury | High Blood Pressure | Neuritis | Neuralgia | Hay Fever | Asthma | Sciatica | Hives | Polio | Meningitis | Thyroid Disease | Frequent Infections or Boils | HIV | AIDS | DT’s | Any Other Disease (specify): ________________________________________

My present weight is: _______________ pounds.

Please circle if you now have or have ever had:

Visual Change | Hearing Change | Ringing in Ears | Fainting Spells | Light Headedness | Blood in urine | Difficulty in Urination | Indigestion | Gas | Belching | Constipation | Diarrhea | Rectal Bleeding | Black Tarry Stools | Numbness | Tingling | Paralysis | Weakness | Dizziness | Vertigo | Headaches | Enlarged Glands | Abnormal Thirst | Chest Pain | Shortness of Breath with Exertion | Shortness of Breath at Night | Varicose Veins | Spitting up Blood | Trouble Swallowing | Trouble with Nose | Trouble with Sinuses | Trouble with Mouth | Trouble with Throat | Convulsions | Palpitation | Fluttering Heart | Swelling of Hands | Swelling of Feet | Swelling of Ankles | Fatigue | Night Sweats | Insomnia | Disorientation | Cough | Tiredness | Weakness | Loss of Appetite | Rash | Prostate Trouble | Heart Burn

Please circle "alternative" treatments you have used or undergone:

Accupuncture | Ear Candling | Echinacea | Ephedra | Homeopathic | Massage | Naturopathic | St. John's Wort


Medicines: List all medicines occasionally or regularly used 
Include aspirin, vitamins, & birth control pills:

___________________________________________________________________________

___________________________________________________________________________

Psychiatric Medicines: List all you have ever used:

___________________________________________________________________________

___________________________________________________________________________

Allergic or have had reactions to these medications:

___________________________________________________________________________

___________________________________________________________________________


Office Policy

WHY YOU SHOULD READ THIS
First we want to thank you for choosing Dr. Edwards as your psychiatrist. Health care has become very complex and demands more than ever that the patient be knowledgeable in order to make decisions about treatment options. It is important that you know your rights and responsibilities as a patient, what you can expect from your psychiatrist, and how psychiatric treatment works. We hope that providing this information in writing will reduce the likelihood of misunderstanding. Please ask the doctor if you need further clarification regarding any of these issues or policies.


DR. EDWARDS IS A PSYCHIATRIST
Today there are professionals of many disciplines providing assessment, medication management, counseling or psychotherapy, some claiming to provide psychiatric services. Among these, psychiatrists alone have an MD (or DO) degree like other physicians. They also have special training in prescribing psychiatric medications. Psychiatry is a medical specialty requiring training beyond that necessary to become a physician.


TRAINING AND QUALIFICATIONS
After graduating from University of Virginia School of Medicine Dr. Edwards completed four years of internship and residency training in the medical specialty of psychiatry at St. Vincent's Hospital in New York City. He was trained in "family systems" psychotherapy at Center for Family Learning in New Rochelle, New York. He is certified by the American Board of Psychiatry and Neurology in "Psychiatry with Added Qualifications in Addiction Psychiatry and with Added Qualifications in Forensic Psychiatry." He is also certified in Addiction Medicine by the American Society of Addiction Medicine. He has been in continuous private practice since 1983.


SERVICES DR. EDWARDS PROVIDES
Your first contact with any physician usually includes a diagnostic examination. At the end of this the doctor discusses your diagnosis and treatment alternatives. Psychiatric treatment usually involves medication or psychotherapy or a combination of the two. Dr. Edwards can also refer you to other professionals if indicated either for consultation or for treatment.

Occasionally a psychiatric diagnosis or treatment becomes an issue in a legal proceeding or insurance claim. Any time Dr. Edwards must spend in connection with such administrative activities will be billed at his basic hourly rate for non-clinical services. This would include, for example, telephone conference with an attorney or insurance case manager, completion of insurance forms, travel time, record review, preparation, court testimony, and deposition.

Dr. Edwards also provides psychiatric expert witness and independent examination services. These services will not be provided to current or prior patients of Dr. Edwards. Dr. Edwards' does not provide treatment to patients he has evaluated as an expert witness or independent examiner in the past.

Dr. Edwards is responsible only for providing diagnosis and treatment services. He is not able to predict or prevent the patient or significant other from harming himself or others or from other actions that might have adverse consequences. Patients are responsible for their behavior.


MEDICATION
There is strong evidence from careful research that many psychiatric disorders involve imbalances of chemicals in the brain. You and Dr. Edwards may consider, as part of your treatment, the use of drugs that can alter these imbalances with an acceptable risk of adverse or "side" effects. Dr. Edwards will usually provide you with information regarding the expected therapeutic effects and side effects prior to or during your treatment as needed. Psychotherapy may be beneficial as well, provided by an independent non-physician psychotherapist of your choice.

Dr. Edwards expects to see you regularly to monitor your response to the medication and any adverse effects you may experience for as long as he is prescribing it for you. These visits will usually last no more than about 15 minutes. Dr. Edwards will want to see you as often as weekly until your treatment has become stable, then visits can be monthly or even less often as indicated.

Medication refills are ordered by fax or Internet Monday through Thursday and Friday mornings only. Do not let yourself run out of medication. It is your responsibility to allow us sufficient time to refill prescriptions during normal business hours. Please call the pharamacy to request a refill. Do not wait until a Friday or the day before a holiday. Dr. Edwards only orders medication refills for active patients with a scheduled follow up appointment. If you expect to run out of medication on the same day you have a scheduled appointment, contact the pharmacy the day before to request a refill. Please do not expect that your prescription will be ready at the pharmacy immediately after your appointment. Always call the pharmacy to be sure your prescription is ready before you go to the pharmacy. If the pharmacy has not received the order, ask the pharmacist to contact Dr. Edwards.

Some third party payers require preauthorization for some medications. The payer may demand Dr. Edwards provide information about your diagnosis and treatment in writing or by telephone. If you want Dr. Edwards to provide this service, payment of a nominal fee in advance and completion of an authorization form is required.

Taking the wrong medication can lead to serious complications, including death. In order to minimize medication errors physician, pharmacist, and patient must each be vigilant. It is the patient's responsibility to examine any medication purchased from a pharmacy at the time of purchase. If you are not sure it is the medication you expect, return it to the pharmacist at the time of purchase and ask the pharmacist to contact Dr. Edwards. Dr. Edwards will not be responsible for reimbursing you for purchasing the wrong medication even if he has ordered the wrong medicine.

Psychiatrists have more training, skill and other qualifications in prescribing medication for mental disorders than other providers. If another provider wants to prescribe medication or other treatment for your psychiatric condition, ask them to discuss this with Dr. Edwards first.


IF YOU ARE PROVIDED PSYCHOTHERAPY SERVICES BY ANOTHER PROFESSIONAL
Many non-psychiatrists are able to provide psychotherapy. If you choose to see Dr. Edwards for medication management only, it is important that you understand that the doctor has no responsibility for the psychotherapy services you receive elsewhere and that Dr. Edwards is unable to assess the psychotherapist's credentials, qualifications, methods, or ethical standing. He will expect you to allow the psychotherapist to keep him apprised of significant changes in your condition or treatment and to allow Dr. Edwards to communicate with the psychotherapist.


TELEPHONE CONTACT
Dr. Edwards expects patients who are experiencing unpleasant or unexpected effects of medications he prescribes to report them by telephone during normal business hours. Bring pressing questions to the next visit or ask for an earlier appointment. Calls from family or friends will not be returned except by prior arrangement. If you expect Dr. Edwards to return a call you must deactivate blocking of calls whose caller ID is blocked. Dr. Edwards will not deactivate ID blocking on his phone to return such a call.


FAMILY
Dr. Edwards may decline to have contact with family members without the identified patient's signed authorization. Dr. Edwards may not ask for express written authorization if family members are present during an office visit. As long as the identified patient is in agreement, it is not necessary to ask permission of or warn Dr. Edwards before a family member attends an office visit. Dr. Edwards asks that family members refrain from contacting him by telephone without the identified patient's knowledge. Likewise, please do not ask Dr. Edwards to schedule a visit without the identified patient present.


EMERGENCIES
Dr. Edwards does not provide emergency services. If you think you need emergency medical attention please call 911, go to the nearest hospital emergency room, or call the Crisis Clinic or County Designated Mental Health Professional. (Check your local directory for the correct phone numbers.)


OFFICE HOURS
Dr. Edwards' office hours vary. Medication management visits are scheduled to end no later than 6:00 PM. The office is closed on weekends.


LATENESS, CANCELLATION AND BROKEN APPOINTMENTS
Dr. Edwards tries to start all appointments on time. Dr. Edwards charges $50.00 for missed appointments. We do not bill insurance for broken appointments since insurance only pays for actual services rendered. If Dr. Edwards is late in starting a session he will attempt to make up the time, but if the patient is late he will not extend the session. If you need to cancel or move an appointment, please call us as soon as you can so another patient can use the appointment time.


WHEN DR. EDWARDS IS NOT AVAILABLE
Dr. Edwards will arrange for another psychiatrist to be available when he is out of town. Please respect that another physician may have different policies. Dr. Edwards will usually provide a brief summary of your case to the physician in case you need medical attention before Dr. Edwards returns. Dr. Edwards may not inform you of a planned absence ahead of time.


STOPPING TREATMENT
Patients may decide to stop treatment altogether or to seek treatment with a different psychiatrist or psychotherapist. Dr. Edwards may encourage you to do so if you do not appear to be benefiting from treatment. Like most important decisions regarding relationships, this one is best made after discussion and input from patient and physician. The success of any physician patient relationship depends greatly on indefinable qualities we sometimes refer to as "chemistry." Because of this Dr. Edwards wants you to feel free to discuss with him your interest in changing to a different physician. He may be able to assist in finding the best provider for your particular needs.

Dr. Edwards may find it necessary to end your treatment without your agreement. For example, this may be done if you choose not to comply with treatment recommendations to such an extent that the treatment is ineffective. Psychiatric services may also be stopped for non-payment of fees. Under certain circumstances Dr. Edwards will remain your physician of record for thirty days after he has advised you that he will no longer provide care. This may or may not include providing continued medication refills at Dr. Edwards discretion. Dr. Edwards will not provide referral to another provider if he believes that there has been a show of bad faith, that you have abused your relationship with the doctor, that you have deliberately harmed yourself or others, or that continued treatment is not likely to help you.


Financial Arrangements

We require payment in full at the time of service except by prior arrangement with the office manager. After you establish your ability to keep your account current you may ask us to bill you monthly. Please check the option which you prefer.

Payment in full at each appointment by:

o Cash o Credit/Debit Card o Personal Check o I wish to discuss the office’s payment policy


INSURANCE
The patient is responsible for securing reimbursement from their health insurance plan for services rendered by Dr. Edwards. Insurance coverage for mental illness varies from generous to none at all. Different companies may have different criteria or definitions for determining what is or is not reimbursable. Most companies cover only what they consider "medically necessary". The criteria for medical necessity differ from company to company. Services provided by Dr. Edwards may not be considered medically necessary by the company or case reviewer. This may mean that the patient's symptoms do not interfere with social or occupational functioning or that the treatment has returned the patient to adequate functioning. If the patient wishes to continue in treatment anyway, it may be without any reimbursement by the insurer. Please do not ask Dr. Edwards to misrepresent diagnosis or level of functioning in order to obtain insurance benefits.


CONFIDENTIALITY & MEDICAL RECORDS
We keep a record of the health care services we provide you. You may ask us to see and copy that record. You may also ask us to correct that record. We may deny these requests under certain circumstances. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. Dr. Edwards may require that you sign an authorization for release of information if you want him to provide information to others, including family members.

Because Dr. Edwards is not a covered entity under HIPAA he is not subject to the requirements of the Privacy Rule.

Dr. Edwards may be required by law to report suspected child abuse. He may be required by law to provide information to others in order to protect someone you threaten to harm. He may be required by law to provide information from your record if ordered to do so by the courts.


Authorization and Release

I authorize the release of any information including the diagnosis and the records of any treatment of examination rendered to me or my child during the period of such care to a third party payer and/or other health practitioners. I authorize the release of information to pharmacies sufficient for ordering prescriptions and refills.

I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf of myself or my dependents. If my insurance company demands refund of payments determined to be overpayments, I agree to reimburse Dr. Edwards immediately.

If I was treated previously by a psychiatrist, physician, psychologist, or other mental health professional, if I was treated previously in a psychiatric hospital, or if am currently treated by any of these, I will ask them to provide Dr. Edwards with copies of their records of my treatment as soon as possible.

I understand that Dr. Edwards has voluntarily excluded himself from Medicare reimbursement and that I agree not to claim benefits from Medicare for any services Dr. Edwards provides to me. If I am eligible or a Medicare beneficiary now, I have signed the contract. I agree to notify Dr. Edwards immediately in the event that I become eligible for Medicare.

 

___________________________________________________________________________
Signature of patient (or parent if minor)                                                      Date

Thank you for filling out this form completely. The information you have provided will help us serve you health care needs more effectively and efficiently. If you have any questions at any time, please ask - we are always happy to help.