Scott R - Suzanne Grantham



Suzanne Grantham, PMHNP

1101 S. Capital of Texas Hwy.

Bldg A, Ste. 200 O: 512.617.6746

Austin, TX 78746 F: 512.329.5522

Psychiatric and Medical History Form

|Patient’s name: | |Date of Birth: | |

|Current Weight: | |Current Height: | feet inches |

|Please give a brief reason for your visit: |

|Current Therapist: | |Ph: |Fax: |

|List any past psychiatric care and medications prescribed: |

|Date |

|Psychiatrist (Name, City and State) |

|Diagnosis / Medications prescribed |

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|List any past psychiatric hospitalizations or substance abuse treatment and their dates: |

|Date |

|Facility (Name, City and State) |

|Type of Treatment |

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|Please check if you have been diagnosed with any of the medical conditions listed below: |

|□ High Blood Pressure □ Seizures □ Asthma □ High Cholesterol □ Head Injury |

|□ Cancer □ Heart Disease □ Migraine □ Liver Disease □ Diabetes |

|□ Glaucoma □ Kidney Disease □ Thyroid Problems □ Chronic Pain □ Sleep Apnea |

|□ Peptic Ulcer Disease □ GERD □ Irritable Bowel Syndrome |

|□ Other Serious Illness(es): |

|Are you currently under medical care for any reason? □ No □ Yes If yes, please explain: |

|List all medications, herbs and nutritional supplements you are now taking: (continue on back if needed…) |

|Medication, Herb or Supplement: |Dose (mg’s, etc.): |Prescribed by: |

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|Allergies: | |

|Primary Care Dr.: | |Ph: |Fax: |

|WOMEN: Please check any of the following that apply: □ I am pregnant (or trying to become pregnant) |

|□ I have regular menstrual periods □ I am perimenopausal □ I am menopausal □ I had a hysterectomy |

|Do you experience variations in mood or anxiety level related to your menstrual period? □ Yes □ No |

| | |Date: | |

|Signature: | | | |

Suzanne Grantham, PMHNP

PATIENT INFORMATION FORM

PLEASE PRINT CLEARLY

Patient Name: DOB:

Address: City/ST: Zip:

Please list only those phone numbers you’re comfortable with us calling and leaving detailed messages:

Preferred Contact Phone #: ( ) □ Home □ Cell □ Work □ Other:

Secondary Contact Phone #: ( ) □ Home □ Cell □ Work □ Other:

Other Contact Phone #: ( ) □ Home □ Cell □ Work □ Other:

TDL:_____________________________ Email Address: ________________________

Social Security Number: Gender: □ Male □ Female

Marital Status: □ Single □ Married □ Life Partner □ Divorced □ Separated □ Widowed

Student Status: □ Full-Time □ Part-Time □ Non-student School Name:

Spouse Name: Phone: ( )

Address (if different):

Emergency Contact:

Emergency Contact Phone: ( ) Relationship:

RESPONSIBLE PARTY INFORMATION

Responsible Party Name (please print):

Address: City/ST: Zip:

Preferred Contact Phone #: ( ) □ Home □ Cell □ Work □ Ok to leave message?

If the responsible party will not be present at time of services (i.e.: parent living out of town) or if you’d like to keep a credit card number on file for your visits, please provide a credit card number below:

□ MC □ Visa □ Discover CC #:

Expiry (MM/YY): / House # of address where cc statement mailed: Zip Code:

Payment in full is required at the time of service. We are happy to provide a walk out receipt for your submission to your insurance company for reimbursement. Any financial concerns should be discussed with the Doctor prior to services being rendered.

I HAVE READ THE ABOVE STATEMENT AND AGREE TO BE PERSONALLY RESPONSIBLE FOR ALL CHARGES AND FEES. ADDITIONALLY, I GIVE MY CONSENT FOR MEDICAL TREATMENT.

Signature of Patient or Responsible Party Date

SUZANNE GRANTHAM, PMHNP

OFFICE POLICIES AND PROCEDURES

APPOINTMENTS: Initial Appointments are scheduled for 90 minutes. Follow-up appointments are scheduled for 30 to 60 minutes.

FEES AND PAYMENTS: Fees for individual sessions are $300 for the initial evaluation, $135 for a 25-30 minute session and $195 for a 50-60 minute session. Our office will only submit claims and accept insurance reimbursements from insurance carriers for which we are listed as in-network. You will be responsible for any coinsurance amounts, co-payments and deductibles as outlined by your insurance carrier. If we are not in-network with your insurance carrier, you will be responsible for payment in full at the time services are rendered. It is this office’s policy to file only primary insurance; secondary insurance will not be filed by our office. All private payments, copayments, coinsurance payments and deductibles are due at the time of each visit. Please provide all pertinent insurance carrier information at your initial visit and/or new insurance information as soon as possible. Failure to provide this information could result in patient responsibility of payment in full of the fees as listed above. An administration fee will be assessed for copies of medical records, letters written on your behalf, or forms completed on your behalf. We do not provide psychiatric assessments for legal cases. Subpoena fees are charged at a minimum of $2,500 per day.

Our staff schedules follow up appointments prior to patient prescriptions running out. Should circumstances arise which prevent you from keeping your scheduled follow up appointment or if you fail to schedule your follow up appointment in a timely manner, we will schedule/reschedule your appointment for the next available opening. There will be a charge of $15.00 for refilling your prescription, if necessary, prior to your next scheduled appointment. Our office does not refill medications on weekends or holidays. We require a 48-hour notice for prescription refills.

If you must cancel your appointment, please call two business days in advance so your time can be available to someone else. Patients who miss their appointment or do not provide two business days notification of cancellation will be financially responsible for the full amount of the session. These sessions cannot be billed to the insurance company and payment in full is due prior to the next appointment. It is difficult to provide effective continuity of care to patients who consistently miss and/or cancel their appointments. Patients who are unable to keep their scheduled appointments and/or consistently miss appointments will receive notification of discontinuation of services via postal service. We will provide 30 days of coverage from the date of the letter to allow time to seek another provider.

Telephone calls directly related to patient care that exceed 10 minutes (not scheduling or insurance matters) will be charged a fee of $70.00. This will not be billed to any insurance company; you will be responsible for payment. Phone contact is encouraged; however, we must be conscientious of time management as to serve and address the needs of all patients in need. If you have an issue that may require more than 5 minutes, we recommend you schedule an appointment.

By signing below, you acknowledge that you have read and understand the policies and procedures as set forth above. Additionally, you give authorization of payment of medical benefits to our office for services rendered. If you have any questions or concerns, please don’t hesitate to communicate with either Suzanne or her office staff. We want to support you in taking care of yourself. The process begins right now. We appreciate the trust you have extended in allowing us to assist you.

________________________

Printed Name of Patient

X ___ ________________ Patient Signature Date

SUZANNE GRANTHAM, PMHNP

OFFICE POLICIES AND PROCEDURES

The following information summarizes our Office Policies and Procedures contained in the New Patient Paperwork you completed and signed in our office. Please read it carefully.

FEES AND PAYMENTS: Patient Initials

Initial Evaluation: $300

Medication Management with Psychotherapy (up to 30 minutes): $135

Medication Management with Psychotherapy (50-60 minutes $195

Phone calls exceeding 5 minutes ($50 for 6-10 minutes and $125 for 11 to 30 minutes)

▪ All private payments, copayments, and deductibles are due at the time of each visit.

▪ Our office only submits claims to insurance companies for which we are “in-network”. Secondary insurance is not filed.

▪ Failure to provide current insurance information could result in patient responsibility of payment in full of the fees as listed above.

MEDICATION REFILLS: Patient Initials

▪ Appointments are scheduled prior to patient prescriptions running out.

▪ We require a 48-hour notice for prescription refills.

▪ There is a $15 prescription refill fee for all controlled substance prescriptions dispensed outside of a scheduled appointment.

▪ Our office does not refill medications on weekends or holidays.

APPOINTMENTS: Patient Initials

▪ Courtesy appointment reminder calls are made 3 business days in advance of your appointment.

▪ Patients arriving 10 minutes after your scheduled appointment time are subject to being rescheduled.

▪ Appointments must be cancelled 48 business hours in advance to avoid a missed appointment charge.

▪ Missed appointments and cancellations made less than 48 business hours prior to your scheduled appointment time will incur a missed appointment fee of $85. After the 2nd missed/late canceled appointment, patients are responsible for the full rate of the scheduled appointment.

▪ Missed appointment fees must be paid prior to the next appointment.

▪ Patients who are consistently unable to keep their scheduled appointments will receive notification of discontinuation of services via postal service.

▪ Patients will be billed $70.00 per 15 min for phone calls that directly relate to patient care that exceed 10 minutes.

MISCELLANEOUS: Patient Initials

▪ Medical Records Requests (not related to SSI determination)

□ Administration fees for copies of medical records are charged as follows per the Texas Medical Board’s guidelines:

Pages 1 – 20: $25.00, then $0.50 per page thereafter plus applicable postage.

▪ Letters

o Letters written on your behalf are charged at $70 per 15 minutes.

▪ Disability and/or Legal Paperwork

□ An appointment must be scheduled for the completion of Long Term or Short Term Disability Forms.

□ We do not provide psychiatric assessments for legal cases.

▪ Subpoenas are charged at a minimum of $2,500 per day.

HOURS OF OPERATION: Patient Initials

Office & Telephone Hours: Monday through Thursday, 10:00 am – 6:00 pm, Friday 9:00 am – 3:00 pm

Appointments available: Monday through Thursday, 9:30 am – 6:00 pm. Friday 9:30- 3:00 pm

Suzanne Grantham, PMHNP

Acknowledgement of Receipt of Notice of Privacy Practices

Printed Name of Patient Printed Name of Parent / Guardian

Relationship to Patient:

Patient OR Parent / Guardian Signature □ Self □ Parent □ Guardian

Suzanne Grantham, PMHNP

Patient Consent Form

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);

• Obtaining payment from third party payers (e.g. my insurance company);

• The day-to-day healthcare operations of your practice. Including calling to remind me of my appointment or at my request (either written or verbal), to fax information to a school or place of employment, that I (or my child) missed school or work due to a medical appointment.

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I, the patient, understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you, the physician, are not required to agree to these restrictions. However, if you, the physician, do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use of disclosure that occurred prior to the date I revoked this consent is not affected.

Signed on the day of , 20 .

Printed Name of Patient Printed Name of Parent / Guardian

Relationship to Patient:

Patient OR Parent / Guardian Signature □ Self □ Parent □ Guardian

Patient Name: Date:

INSTRUCTIONS: The symptoms of anxiety can be divided into those effecting feelings, thoughts, and the body. To find out the level of your anxiety, put a check (√) in the space to the right that best describes how much that symptom or problem has bothered you during the past week.

| |Not at all |Somewhat |Moderate |A lot |

|Category I: Anxious Feelings |0 |1 |2 |3 |

|1. Anxiety, nervousness, worry or fear. | | | | |

|2. Feeling that things around you are strange, unreal or foggy. | | | | |

|3. Feeling detached from all or part of your body. | | | | |

|4. Sudden, unexpected panic spells. | | | | |

|5. Apprehension or a sense of impending doom. | | | | |

|6. Feeling tense, stressed, “uptight” or on edge. | | | | |

| |Not at all |Somewhat |Moderate |A lot |

|Category II: Anxious Thoughts |0 |1 |2 |3 |

|7. Difficulty concentrating. | | | | |

|8. Racing thoughts or having your mind jump from one thing to the next. | | | | |

|9. Frightening fantasies or daydreams. | | | | |

|10. Feeling that you’re on the verge of losing control. | | | | |

|11. Fears of cracking up or going crazy. | | | | |

|12. Fears of fainting or passing out. | | | | |

|13. Fears of physical illness or heart attacks or dying. | | | | |

|14. Concerns about looking foolish or inadequate in front of others. | | | | |

|15. Fears of being alone, isolated, or abandoned. | | | | |

|16. Fears of criticism or disapproval. | | | | |

|17. Fears that something terrible is about to happen. | | | | |

| |Not at all |Somewhat |Moderate |A lot |

|Category III: Physical Symptoms |0 |1 |2 |3 |

|18. Skipping, racing or pounding of the heart (sometimes called palpitations). | | | | |

|19. Pain, pressure or tightness in the chest. | | | | |

|20. Tingling or numbness in the toes or fingers. | | | | |

|21. Butterflies or discomfort in the stomach. | | | | |

|22. Constipation or diarrhea. | | | | |

| |Not at all |Somewhat |Moderate |A lot |

|Category III: Physical Symptoms, cont. |0 |1 |2 |3 |

|23. Restlessness or jumpiness. | | | | |

|24. Tight, tense muscles. | | | | |

|25. Sweating not brought on by heat. | | | | |

|26. A lump in the throat. | | | | |

|27. Trembling or shaking. | | | | |

|28. Rubbery or “jelly” legs. | | | | |

|29. Feeling dizzy, light-headed or off balance. | | | | |

|30. Choking or smothering sensations or difficulty breathing. | | | | |

|31. Headaches or pains in the neck or back. | | | | |

|32. Hot flashes or cold chills. | | | | |

|33. Feeling tired, weak, or easily exhausted. | | | | |

Interpreting your anxiety score:

0 – 5: Minimal

6 – 15: Mild

16 – 30: Moderate

31 – 50: Severe

Over 50: Extreme

THE MOOD DISORDER QUESTIONNAIRE

Instructions: Please answer each question as best you can. Upon completing this form, you will be able to print your completed form and take it to your health care practitioner.

|1. Has there ever been a period of time when you were not your usual self and… | | |

|...you felt so good or hyper that other people thought you were not your normal self or you were so hyper that you got into |O YES |O NO |

|trouble? | | |

|…you were so irritable that you shouted at people or started fights or arguments? |O YES |O NO |

|…you felt much more self-confident than usual? |O YES |O NO |

|…you got much less sleep than usual and found you didn’t really miss it? |O YES |O NO |

|…you were much more talkative or spoke much faster than usual: |O YES |O NO |

|…thoughts raced through your head or you couldn’t slow your mind down? |O YES |O NO |

|…you were so easily distracted by things around you that you had trouble concentrating or staying on track? |O YES |O NO |

|…you had much more energy than usual? |O YES |O NO |

|…you were much more active or did many more things than usual? |O YES |O NO |

|…you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? |O YES |O NO |

|…you were much more interested in sex than usual? |O YES |O NO |

|…you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? |O YES |O NO |

|…spending money got you or your family into trouble? |O YES |O NO |

|2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? |O YES |O NO |

|3. How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; | | |

|getting into arguments or fights? Please select one response only. | | |

O No problem O Minor Problem O Moderate Problem O Serious Problem

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BSDS

Instructions:

1. Please read through the entire passage below before filling in any blanks.

Some individuals notice that their mood and/or energy levels shift drastically from time to time___. These individuals notice that, at times, their mood and/or energy level is very low, and at other times, very high___. During their ‘‘low’’ phases, these individuals often feel a lack of energy; a need to stay in bed or get extra sleep; and little or no motivation to do things they need to do___. They often put on weight during these periods___. During their low phases, these individuals often feel ‘‘blue’’, sad all the time, or depressed___. Sometimes, during these low phases, they feel hopeless or even suicidal___. Their ability to function at work or socially is impaired___. Typically, these low phases last for a few weeks, but sometimes they last only a few days___. Individuals with this type of pattern may experience a period of ‘‘normal’’ mood in between mood swings, during which their mood and energy level feels ‘‘right’’ and their ability

to function is not disturbed___. They may then notice a marked shift or ‘‘switch’’ in the way they feel___. Their energy increases above what is normal for them, and they often get many things done they would not ordinarily be able to do___. Sometimes, during these ‘‘high’’ periods, these individuals feel as if they have too much energy or feel ‘‘hyper’’___. Some individuals, during these high periods, may feel irritable, ‘‘on edge’’, or aggressive___. Some individuals, during these high periods, take on too many activities at once___. During these high periods, some individuals may spend money in ways that cause them trouble___. They may be more talkative, outgoing, or sexual during these periods___. Sometimes, their behavior during these high periods seems strange or annoying to others___. Sometimes, these individuals get into

difficulty with co-workers or the police, during these high periods___. Sometimes, they increase their alcohol or non-prescription drug use during these high periods___.

2. Now that you have read this passage, please check one of the following four boxes:

( ) This story fits me very well, or almost perfectly

( ) This story fits me fairly well

( ) This story fits me to some degree, but not in most respects

( ) This story does not really describe me at all

3. Now please go back and put a check after each sentence that definitely describes you.

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For Our Office Use Only

Our office attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained for the following reason:

□ Patient refused to sign acknowledgment.

□ Communication barriers prohibited obtaining the acknowledgement.

□ An emergency situation prevented us from obtaining acknowledgement

□ Other (describe below):

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***Employee must sign and date***

Printed Employee Name

Signature of Employee Date

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