"*" indicates required fields

PATIENT INFORMATION

Your Name:*
Birth Date:
Sex:
Marital Status:
Child:
Ethnicity:
Race:
Parents Name /Legal Guardian if Patient is a Minor:
Address

IN CASE OF EMERGENCY

INSURANCE / GUARANTOR INFORMATION

Is the Patient Covered by Insurance:
Is the Guarantor a Patient Here:
MM slash DD slash YYYY
Patient's Relationship to Subscriber:
Patient's Relationship to Subscriber:

AUTHORIZATION / ACKNOWLEDGMENT

By signing below, I authorize the provider to treat my dependent or myself, to file the insurance on my/our behalf, and to accept assignments on the claims filed. In addition, the above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Achieve MD or insurance company to release any information required to process my claims.

HIPAA 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 IT CAREFULLY.

This notice of Privacy Practices describes how we may use and disclose you protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “protected health information” is information about you, including demographic information, that may identify you and that, related to your past, present, or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment:

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services; this includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has necessary information to diagnose or treat you.

Payment:

Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain for the hospital admission.

Healthcare Operations:

We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at registration desk where you will be asked to sign your name and indicate your physician. WE may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, Public Heath issues as require by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration Requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Sections 164.500.

Other Permitted and Required Uses and Disclosures

Will be made only with Your Consent, Authorization or Opportunity to object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indication in the authorization.

Your Rights:

Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information.

Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information.

This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care of for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request.

If your physician believes, it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use a Healthcare Professional.

-You have the right to request to receive confidential communications from us by alternative means or at an alternative location.

-You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

-You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

-We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints:

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complain. We will not retaliate against you for filing a complaint. This notice was published and in effect on April 14, 2013 We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information, If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

By checking the box below, I acknowledge and agree that I have read and received a copy of Achieve MD’s HIPAA Policy:*

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize Achieve MD to release/share health information and records for the following individual:

MM slash DD slash YYYY

Do We Have Permission To:

Leave a message on your answering machine at home?
Leave a message at your place of employment?
Leave a message on your cell phone?
Discuss your medical information with a member of your family?
If yes, please list family members names:
Column 1
Column 2
Column 3
 

PRIMARY CARE PHYSICIAN

If there is any additional places or people that may need to request your records or have your records submitted to please state below:

Check all that apply:
1.
Name
Address
Phone No.
Fax No.
2.
Name
Address
Phone No.
Fax No.
The purpose of this disclosure is (check all that apply):

Information to be used or disclosed includes only those items checked below with respect to services provided on or around (dates of service):

If the 'dates of service' field is left blank, the treatment dates covered by this authorization include the date of intake to the last date of service.

Please select below:

CONSENT FOR RELEASE OF INFORMATION

I authorize the above-named person/entity to have access to (verbal and/or written) copies of the above-specified records for the listed purpose. I understand that this authorization can only be revoked by my written request.*

Achieve MD PATIENT POLICIES

Thank you for choosing Achieve MD as your healthcare provider. We are committed to building a successful physician-patient relationship with you. It is important that you have a clear understanding of our patient policies and financial policies. Please understand that payment for services is part of that relationship. It is your responsibility to notify our office of any patient information changes (i.e. address, phone number, insurance, etc.)

Co-Pays

Please be prepared to pay your co-pay amount at each visit and have a copy of your current insurance card. We understand you may feel this unnecessary, however insurance plans are becoming more complicated and changes to policies are happening more frequently. In order to file your claims correctly, we must have the most current card on file. Failure to provide complete insurance information may result in patient responsibility for the entire bill. Most plans require we file a claim within 90 days from the date of service. If we have not received your information within that time, you will remain responsible for all charges incurred up to the date you provide us with your insurance information and we received payment from the insurance plan. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance.

Release of Medical Records

Medical records are confidential documents and are only released when permitted by law or with proper written authorization of the patient. Upon request, medical records are released in a timely manner to the patient or the patient’s representative, unless such a release would endanger the patient’s life or cause harm to another person. This includes medical records received from other physicians’ offices or health care facilities.

The following supporting directives are followed when releasing medical information:

1. The patient representatives must have submitted a written request (procedure) or granted written permission before copies of medical information will be released.

2. Achieve MD will not fax or mail medical information to individuals. Medical records must be picked up in person, with valid ID.

3. Achieve MD will not release medical records to patients with an outstanding balance.

4. Achieve MD will implement a 20$ processing fee for release of medical records.

-Self-Pay Account:

Self-pay accounts are patients without insurance coverage, or patients without an insurance card on file with us. If services are paid in full at the time of service, we will apply 20% discount off your charges for that day. This discount does not apply to billed services. Please ask to speak with the billing representative if you are unable to pay your bill in full before you are seen by the physician.

-Methods of Payment

We will gladly accept cash, checks, or credit card (Visa, MasterCard, American Express and Discover) as methods of payment.

-Missed Appointments

Achieve MD requires a 24-hour notice of appointment cancellation. Missed appointments that are not cancelled 24 hours in advanced will be charged a 25$ fee. You will be financially responsible for this fee, as insurance plans do not cover this charge. We do understand that emergencies and/or extenuating circumstances arise occasionally and will work with patients on a case-by-case basis.

-Returned Checks

The charge for a returned check is $30.00 payable by cash, credit card or money order. This fee will be added to the account. Following a returned check, all future payments must be made by cash or credit card as we will no longer be able to accept a check as method of payment.

-Outstanding Balance Policy

It is our policy to collect outstanding balances at each visit. If payment cannot be made in full, you will need to speak with our billing representative. We will send 3 statements on outstanding accounts of $5.00 or more. If payment is not made on the account, it will be sent to the collection agency for processing. Once the account is turned over to the collection agency, a 20% collection fee will be added to the account and the person (18 years and older) financially responsible for the account will also be responsible for all collection’s costs. At this point you may be discharged from our practice.

Please be sure to read this document completely. This financial policy helps our office provide quality care to all of our patients. If you should have any questions, please ask to speak to a billing representative or office manager.

Assessment and/or Testing

Testing is billed on the basis of the type of test and the amount of time necessary to administer, score, analyze, interpret and to report the results in written form. You will be provided with information about the type of test and the cost prior to testing if during the evaluation process it is discovered that additional testing is required to make a final diagnosis, you will be informed before any additional procedures are initiated. The written report is generated after payment in full for testing services is received.

Reports

Reports not included in the assessment and/or testing fees will be billed as a separate procedure. Requests for such reports and fees will be discussed with you in advance.

Drug Screen Policy

It is Achieve MD’s policy to perform random drug screenings on each patient. Failure to comply with this policy or tampering with the test could result in the patient’s dismissal from the practice.

Confidentiality

Communication between you and your doctor / psychologist is considered privileged and confidential. The only exception to these conditions may occur in situations such as child abuse or danger to your life. Please discuss this with your doctor / psychologist.

I have read and understand Achieve MD financial, drug screening, consent for medical and or psychological services, and all other patient policies and have been given the opportunity to ask questions regarding this policy. I acknowledge responsibility for all fees incurred.*

INFORMED CONSENT FOR MEDICAL SERVICES:

I hereby voluntarily apply for and consent to medical services by Achieve MD.This consent applies to myself, ward or client named below. Since I have the right to refuse services at any time, I understand and agree that my continued participation implies voluntary informed consent. I understand that the potential benefits of receiving services may include obtaining a professional opinion, reduction of symptoms and an increased understanding of issues. I understand that potential risks may include possible disagreement with the professional opinions offered, possible emotional distress when addressing my difficulties, and limitations in the ability to make predictions based on results of psychological assessments (when applicable). I understand that alternative procedures include services provided by another psychologist, a psychiatrist, or another health professional. I understand that I may ask for a referral to another health professional if I am not satisfied with my services.

I understand and agree that disclosures and communications are considered privileged and confidential except to the extent that I authorize a release of information or under certain other conditions listed below:

1. Where abuse or harmful neglect of children, the elderly or a disabled or incompetent individual is known or reasonably suspected.

2. Where the validity of a will of a former patient is contested

3. Where such information is necessary for the practitioner to defend against a malpractice action brought by the client.

4. Where an immediate threat of physical violence or suicide against a readily identifiable victim is disclosed to the practitioner.

5. Where the client, by alleging mental or emotional; damages in litigation, put his/her mental state at issue.

6. Where the client is examined pursuant to a court order.

ACKNOWLEDGEMENT & AGREEMENT

Patient/Guarantor Signature (if patient is minor):

SYSTEMS REVIEW
*Please check if you have or has had any of these complaints*

Neurological:
Gastrointestinal:
Metabolic:
Cardiorespiratory:
GU:
Musculoskeletal:
Psychiatric:
Sleep Problems:
Dental Problems:
Skin:
Hematologic:
Immunologic:
MM slash DD slash YYYY
MM slash DD slash YYYY

Developmental-Behavioral Medical History:
**Please fill out this form to the best of your ability and further explain in “Notes” section, if necessary**

Has your child ever received any therapy services from the following (Check all that apply):

Birth, Medical, Developmental History:

Pregnancy:

Prenatal complications:
Complications during delivery:
Postnatal complications/NICU:
Birth defect/Genetic abnormality:

Special Senses:

Vision concerns:
Hearing concerns:

Medical Problems:

Immune deficiency:
Recurrent ear infections:
Seizures/Epilepsy:
Concussion/head injury:
Weakness/paralysis/cerebral palsy:
Tics/Tourette’s:
Other neurologic problem/sees neurology:
Sleep apnea:
Fainting spells/Syncope:
Heart problems/sees cardiology:
Serious accident/injury:
Adverse reaction to an immunization:
Allergic/adverse reaction to medication:
Other health concerns:

Developmental Concerns:

Concerns with your child’s speech:
Concerns with your child’s motor skills:
Concerns with your child’s self-care skills:
Concerns with your child’s social skills:
Concerns with your child’s learning ability:
MM slash DD slash YYYY
MM slash DD slash YYYY
MEDICATIONS

Is your child taking any medication currently?
If yes, please list below:
Name of Medication
Dose
Side Effects
Response to Medication
 
Has your child ever taken medications for behavior, ADHD, anxiety, depression, or sleep?
If yes, please list below:
Name of Medication
Dose
Side Effects
Response to Medication
 

FAMILY HISTORY
Mark any parents, grandparents, aunts, uncles, or sibling diagnosed with any of the following:

ADHD/ADD:
Anxiety:
Depression:
Autism:
Bipolar:
Emotional Problems:
Schizophrenia:
Drug/Alcohol abuse:
Seizures:
Neurological disorders:
Genetic disorders:
Intellectual disability:
Speech problems:
Specific learning disability:
Dyslexia:
Heart attack < age 50:
Heart disease < age 50:
Sudden death any age:
MM slash DD slash YYYY
MM slash DD slash YYYY

SOCIAL HISTORY
Who lives in the home with your child? If parents are divorced or have split custody, or if your child spends time in more than one home (e.g., with grandparents), please list who lives in each home.

SCHOOL HISTORY

Is your child’s behavior at school problematic?
Does your child enjoy school?
Has your child ever been suspended from school or from the bus, or received in-school suspension?
Was your child retained in a grade?
Has your child been expelled from school or had to atend an alternative school setting?
Does your child have a current 504 plan?
Does your child have a current Individualized Education Plan (IEP)?
Please bring a copy of the IEP.
MM slash DD slash YYYY
MM slash DD slash YYYY

SCREENING FOR ADHD


For each of the behavioral symptoms described below, please describe how often your child has shown this symptom over the past six months.
Respond N (never shows this symptom), S (sometimes shows this symptom), O (often shows this symptom), or A (always shows this symptom)

Inattention:

Fails to give close attention to details, makes careless mistakes. (E.g., Younger children may reverse letters or numbers. Older children may miss a math problem due to not noticing a + or – sign even though they know how to work the problem easily. They may misread questions on a test and get the wrong answer even though they are able to read the questions and know the answers.)
Has difficulty concentrating or remaining focused on a task or activity that they can do relatively easily. (E.g., Listening to a teacher’s instructions or lecture, participating in a conversation, continuing to work until a task is complete, or reading a longer passage.)
Does not listen when spoken to directly. (E.g., May “zone out” during a conversation or while teacher is giving instructions and miss part of the information, need to have the information repeated.)
Does not follow through on instructions, does not complete tasks or assignments May start a task but does not complete before getting started on something else. (E.g., If you tell your child, “Go to your room, put on your shoes, bring me your bookbag,” do you have to repeat the instructions or redirect before your child completes all three tasks?)
Has difficulty organizing tasks and activities. Has difficulty keeping materials and belongings in order, has messy or disorganized work or workspace, has poor time management. (E.g., Does not prioritize what needs to be done first before doing what they want to do.)
Avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort. (E.g., Doing homework, completing reports or projects for school.)
Loses things necessary for tasks or activities. May misplace things and have difficulty finding them when needed. (E.g., Pencils, paper, books, water botles, jackets, shoes, keys, glasses, cell phones, etc.)
Is easily distracted by extraneous stimuli. (E.g., Distracted by other students in the class talking, sharpening pencils, or moving around, distracted by activity in the hallway or outside the classroom window, or even distracted by their own thoughts or by drawing or doodling on their paper.)
Is forgetful in daily activities. (E.g., Forgets to bring home items such as a jacket or water bottle, forgets to have parents sign a permission form for a field trip, forgets to complete chores or run necessary errands. Adolescents may forget to return calls or keep appointments.)

Hyperactivity and Impulsiveness:

Fidgets, taps hands or feet, bounces leg, squirms in seat, etc.
Leaves seat in situations where remaining seated is expected. (E.g., In the classroom, at the dinner table or in a restaurant, when watching a TV show or movie, etc.)
Runs, climbs, crawls around or rolls on the floor in situations where it is inappropriate. In adolescents this may be limited to feeling restless.
Is unable to play quietly or do quiet leisure activities. (Not including using electronic devices.)
Is “on the go” or acts as if “driven by a motor.”
Talks excessively. (May make vocal “sound effects” constantly.)
Blurts out an answer before a question is completed or blurts out something unrelated in the middle of a conversation.
Has difficulty waiting his or her turn. May be impatient waiting at a traffic light or when waiting for an appointment or activity to start.
Interrupts or intrudes on others. (Butts into conversations of others, may start to use someone else’s things without asking for or receiving permission, may take over what someone else is doing.)
Do these problems affect:
MM slash DD slash YYYY
MM slash DD slash YYYY

Screening for Anxiety and Depression


Over the last 2 weeks, how often have you (adolescent)/your child (parent competing) been bothered by any of the following problems?

Little interest or pleasure in doing things:
Feeling down, depressed, or hopeless:
Trouble falling/staying asleep:
Sleeping too much:
Feeling tired or having little energy:
Having a poor appetite, not wanting to eat:
Eating too much:
Feeling bad about yourself:
Feeling that you are a failure:
Feeling that you have let yourself or your family down:
Trouble concentrating on things, such as reading the newspaper or watching television:
Moving or speaking so slowly that other people notice:
Being so fidgety or restless that you have been moving around much more than usual:
Wishing that you never existed:
Thoughts that you would be better off dead or of hurting yourself in some way:
If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Over the last 2 weeks, how often have you (adolescent)/your child (parent completing) been bothered by any of the following problems?

Feeling nervous, anxious, or on edge:
Not being able to stop or control worrying:
Worrying too much about different things:
Having trouble relaxing:
Being so restless that it’s hard to sit still:
Becoming easily annoyed or irritable:
Feeling afraid as if something awful might happen:
Being overly self-conscious:
Being afraid to try for fear of making a mistake:
Overly upset if work is not “perfect.” (handwriting not perfect, missed an answer, etc.):
If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
MM slash DD slash YYYY
MM slash DD slash YYYY

Screening for oppositional and defiant behavior and disruptive mood problems

For each of the behavioral symptoms described below, please describe how often your child has shown this symptom over the past six months.
Respond N (never shows this symptom), S (sometimes shows this symptom), O (often shows this symptom), or A (always shows this symptom)

Oppositional and defiant behavior:

Often and easily loses temper:
Is frequently touchy and easily annoyed by others:
Is often angry and resentful:
Often argues with adults or people in authority:
Often actively defies or refuses to follow adults' requests or rules:
Often deliberately annoys or upsets other people:
Often blames others for their own mistakes or misbehavior:
Has shown spiteful or vindictive behavior at least twice in the past six months:
With whom do these behaviors occur?

For each of the behavioral symptoms described below, please describe whether your child shows these symptoms.

Disruptive mood problems and Intermittent Explosive Outbursts:

Severe, recurrent temper outbursts involving verbal rage toward other people out of proportion to the situation or provocation:
Severe, recurrent temper outbursts involving physical aggression toward people or property out of proportion to the situation or provocation:
Outbursts are much more severe than expected for developmental level:
Are the outbursts impulsive and/or anger based?
Are the outbursts premeditated to intimidate others or to gain power or possession?
Mood between outbursts is usually angry or irritable most of the day nearly every day:
Do the outbursts cause distress or remorse in the child afterward?
With whom do these behaviors occur?
MM slash DD slash YYYY
MM slash DD slash YYYY

Screening for Learning Problems

Has your child been tested for learning disabilities or special needs services at school?
If YES, please provide us with a copy of the most recent psychological evaluation and/or IEP.

If your child does NOT have an IEP, please describe for each of the following areas if your child:
(N) has no difficulty, (S) struggles with this but is at grade level, or (B) struggles with this and is below grade level.

Reading:

Difficulty learning and remembering the names and sounds of letters:
Struggling to learn sequential lists, such as the alphabet or days of the week:
Difficulty attaching sounds to letters:
Difficulty sounding out words phonetically:
Inability to sound out the pronunciation of an unfamiliar word or a multiple syllable word:
Difficulty seeing (and occasionally hearing) similarities and differences in letters and words:
Difficulty recognizing rhyming words or finding a word that rhymes with another:
Confusion over letters that look similar (e.g., reading “b” instead of “d”):
Reading slowly or making numerous mistakes while reading aloud:
Understanding what they read:
Recalling correctly (answering questions about) what they read:
Making inferences or predictions based on their reading:
Making conclusions based on their reading:
Avoiding activities that involve reading:

Written Language:

Trouble recalling how to form or orient letters (writing letters backwards):
Slow handwriting that takes a lot of effort:
Handwriting that's hard to read:
Spelling that’s unpredictable and inconsistent:
Confusing the order of letters in words:
Problems remembering the sequence of things:
Problems copying written language:
Taking longer than expected to complete written work:
Trouble putting thoughts into writing:
Written text that is poorly organized or hard to understand:
Trouble with grammar and punctuation:

Math:

Difficulty learning to count objects:
Difficulty understanding how numbers work and relate to each other:
Difficulty learning math facts:
Difficulty solving math problems:
Difficulty learning basic math rules:
Difficulty using math symbols:
Difficulty understanding word problems:
Difficulty organizing and recording information while solving a math problem:

Nonverbal Skills:

Difficulty understanding and following instructions:
Difficulty perceiving where objects are:
Difficulty understanding abstract concepts:
Difficulty reading people's emotions through facial expressions and other cues:
Difficulty with physical coordination:
Difficulty with fine motor skills, such as writing:
Difficulty paying attention, planning, and organizing:
Difficulty understanding higher-level reading or writing tasks (“reading between the lines”):
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.