H Berryman Edwards, MD, FAPA

Welcome

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 oMinor oSingle oMarried oDivorced oWidowed oSeparated

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 Car

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:

My present weight is: _______________ pounds.

Please circle if you now have or have ever had:

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

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:

___________________________________________________________________________

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 Personal Check o I wish to discuss the office’s payment policy

Late Charges

If I do not pay the entire new balance within 25 days of the monthly billing date, a late charge of 1% on the balance then unpaid and owed along with a $5.00 bookkeeping fee will be assessed each month. I realize that failure to keep this account current may result in you being unable to provide additional services except for emergencies or where there is prepayment for additional services. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.

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 and request my insurance company to pay directly to the doctor or doctor’s group insurance benefits otherwise payable to me.

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 or my dependents.

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 in the event that I become eligible for Medicare.

I acknowledge that I have received a copy of the Notice of Privacy Practices of H Berryman Edwards, MD, FAPA, effective 4.14.2003.

I have reviewed Dr. Edwards' Office Policy for Patients and Patients' Rights and Responsibilities.

___________________________________________________________________________
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.