Storage.googleapis.com



MURALI VEERAMACHANENI, M.D. ADULT PPWKBARBARA NEFSTEAD, A.N.P. PATIENT ID #22 CARE CIRCLE, AMARILLO, TX 79124 ______PHONE: 806-354-8300FAX: 806-354-9962FOR OFFICE USE ONLY:DATE OF APPOINTMENT:__________TIME:_____APPT WITH MV BNDEAR PATIENT OR FAMILY,PLEASE FILL OUT ALL ATTACHED FORMS AND RETURN THEM ALONG WITH A COPY OF YOUR INSURANCE CARD(S). WE WILL CONTACT YOU WITHIN 7-14 BUSINESS DAYS WITH AN APPOINTMENT AFTER RETURNING THIS PAPERWORK. IT IS YOUR RESPONSIBILITY TO CALL YOUR INSURANCE COMPANY REGARDING MENTAL HEALTH BENEFITS.PLEASE CONTACT THE OFFICE 24 HOURS BEFORE SCHEDULED APPOINTMENT IF YOU ARE UNABLE TO MAKE IT OR YOU WILL BE BILLED A $180 FEE.NAME OF PATIENT:____________________________DATE:_________IF FOLLOWING APPLIES PLEASE FILL OUT:NAME OF GUARDIAN:__________________________DATE:_________PATIENT/GUARDIAN SIGNATURE:______________________________DATE:_______PATIENT REGISTRATIONPATIENT INFORMATION:PATIENT NAME:____________________________ BIRTHDATE:____________SSN:_____-_____-_____ SEX:_________________ADDRESS:_____________________________________________________________________CITY, STATE, ZIP:________________________________________________________________IF APPLIES OCCUPATION:_________________________________________________________REQUIRED EMAIL ADDRESS:_______________________________________________________HOME:(___)-___-____ CELL:(___)-___-___ WORK:(___)-___-____BEST CONTACT METHOD:__________________PERMISSION TO CALL FOR APPOINTMENT REMINDERS: YES/NO (CIRCLE ONE)PATIENT’S PHARMACY:____________________________________________________________RESPONSIBLE PARTY:(IF PATIENT IS A MINOR OR REQUIRES A GUARDIAN FILL OUT BELOW)GUARDIAN NAME:____________________________________ BIRTHDATE:______________SSN:____-_____-_____ SEX:____________RELATION TO PATIENT:_____________________HOME:(____)-____-____ CELL:(____)-____-____ WORK:(____)-_____-_____BEST CONTACT METHOD:_____________________ADDRESS:_____________________________________________________________________CITY, STATE, ZIP:________________________________________________________________EMPLOYER:________________________________REFERRAL SOURCE:REFERRING PHYSICIAN/OTHER:______________________ PHONE:(____)-_____-_____MAY WE EXCHANGE MEDICAL INFORMATION WITH YOUR TREATING PHYSICIANS/THERAPIST TO CORDINATE YOUR CARE? YES/NO (CIRCLE ONE)PATIENT/GUARDIAN SIGNATURE:__________________________________________________ASSIGNMENT OF INSURANCE BENEFITS FOR PAYMENT FROM YOUR INSURANCE CARRIERPRIMARY INSURANCE: SECONDARY INSURANCE:CARRIER NAME:__________________ CARRIER NAME:__________________ID #____________________________ ID #____________________________GROUP NAME/NUMBER:___________ GROUP NAME/NUMBER:___________INS. PHONE #:(____)-______-_______ INS. PHONE #:(____)-______-_______INSURED PARTY INFORMATION: INSURED PARTY INFORMATION:(IF OTHER THAN PATIENT): (IF OTHER THAN PATIENT):NAME:_________________________ NAME:__________________________DATE OF BIRTH:_____/_____/______ DATE OF BIRTH:_____/______/______ADDRESS:_______________________ ADDRESS:________________________SSN:____-_____-_____ SSN:_____-_____-______EMPLOYER:______________________ EMPLOYER:______________________RELATION TO PATIENT:____________ RELATION TO PATIENT:_____________CONSENT TO RELEASE CLAIMS INFORMATION AND ASSIGNMENT BENEFITS: PLEASE CHECK BOXI HEREBY ASSIGN, TRANSFER, AND SET OVER TO THE PHYSICIAN ALL MY RIGHTS, TITLE, AND INTEREST TO MY MEDICAL REIMBURSMENT BENEFITS UNDER MY INSURANCE POLICY WITH THE ABOVE INSURANCE COMPANY(IES).I HEREBY CONSENT FOR THE PHYSICIAN AND ANY OF ITS EMPLOYEES OR AGENTS TO RELEASE AND DISCLOSE ANY INFORMATION REQUIRED ABOUT ME (OR THE ABOVE-NAMED PATIENT) TO MY INSURANCE CARRIER, CLAIMS ADMINISTRATOR, MANAGED CARE COMPANY, OR REVIEW AGENCY, THEIR EMPLOYEES OR AGENTS FOR TREATMENT, HEALTHCARE OPERATIONS, AND EVALUATING CLAIMS FOR PAYMENT.I UNDERSTAND INSURANCE BILLING IS A SERVICE PROVIDED AS A COURTESY, AND THAT I AM ALWAYS PERSONALLY RESPONSIBLE FOR ANY FEES NOT COVERED BY MY INSURANCE CARRIER. SHOULD ANY INSURANCE PAYMENT BE MADE DIRECTLY TO ME OR TO THE INSURED FOR MONIES DUE ON THIS ACCOUNT, I AGREE TO IMMEDIATELY PAY OVER THESE FUNDS TO THE PHYSICIAN. I ALSO ACKNOWLEDGE I AM RESPOSIBLE FOR ANY DEDUCTIBLE, COPAY, OR OTHER BALANCE NOT COVERED NOT COVERED BY MY INSURANCE CARRIER._______________________________________ ________________PATIENT/GUARDIAN SIGNATURE DATEMurali Veeramachaneni, M.D., P.A. Child, Adolescent and Adult Psychiatry Barbara Nefstead, ANPTel: 806-354-8300 Fax: 806-354-9962 22 Care Circle Amarillo, TX 79124 Cancellations/Missed Appointments To help us serve our patients effectively with the limited number of sessions available we require notice of one full business day (24 hours) for cancellation and reschedules. Monday appointments require notification before 2:00p.m. the preceding business day. Also, any appointments following a holiday require notifications of cancellations before 5:00pm on the preceding business day. This policy extends to cancellations for any reason. You will be charged $ 50.00 for each missed follow up appointment unless we receive such notification. Please be aware that Insurances companies, Medicare and Medicaid will not reimburse for missed appointments, making you responsible for the charged fees. Patients on Medicare, Medicaid, CHIP and Tricare will also be charged for missed appointments by your consent to this agreement.YOU WILL BE DISCHARGED FROM OUR SERVICES IF YOU MISS TWO CONSECUTIVE APPOINTMENTS.TelephoneOur secretary or the answering service – depending on the time of the call answers all calls to our office. A psychiatrist is on call for the patients always and can be reached though the answering service.NO REFILLS WILL BE DONE AFTER HOURS.If a situation requires an immediate response and is life threatening Call 911 or go to the nearest Emergency Room.Fees and Payments Our Regular charges are based on either an initial visit or follow up. Co-Payments are expected at the time of service. Outstanding balance are billed on monthly basis and payments is expected in full by the end of the month. Any collections, legal fees, or cost necessary to collect unpaid balances will be your responsibility. Overdue accounts are sent to a collection agency after a warning letter. We will use our discretion to send any balances that is overdue by 2 months to collections at which point you will need to pay the Collection Agency. We will charge a fee based on our discretion for releasing records to a third party including you. This fee will cover our processing costs. Managed Care Insurance If we participant in your plan, we will comply with the agreement we have with your insurance or managed care company (MCO). It is your responsibility to follow any plan requirements that apply to you. For example, some plans require that you obtain a referral to us before the first session from your primary care physician or case manager. Most plans limit the service for which they reimburse. If you request or agree to a service for which reimbursement is later denied by your insurance company or ins agent (not preauthorized, considered medically unnecessary, beyond the benefit limit, etc..) then you assume the responsibility of paying the entire balance. You should know that MCO routinely request treatment information from us and if you want to use your health care benefits to partially pay for our services then it is likely that the release of confidential treatment information will be required before payment is made. Once we release confidential information, we no longer have any control over where it goes and how many people see it. We recommend that you check your coverage for mental health benefits thoroughly.Confidentiality A record of your treatment is maintained in our office. All issues discussed during treatment are strictly confidential with the following exceptions:Consultation with other health care providers of pertinent to treatment. (such as your primary care physician)Instances where patients may be an imminent threat to self or others, unable to take care of his or her basic needs, or in cases of suspected child abuse. Consultation with colleague, within our call coverage group. Under certain circumstances when ordered by the court.Some treatments information such as name, diagnosis, date of service and charge is routinely given to insurance or managed care companies to facilitate reimbursement. If you have any questions regarding these issues or others we encourage you to discuss them with us.Authorization for treatment agreement to pay: I request and authorize treatment for myself or for the patient herein named. I further agree to pay for services rendered to the patient or myself because of this authorization. Assignment of insurance benefits/release of information: I hereby assign my right to benefits or payments from my insurance companies to this provider. By my signature below, I authorize the release of medical records or other information necessary to process the claim for my insurance if I have a release signed with my insurance Company they can also have records of treatment requested from this office. Patient/Guarantor Signature _____________________________________________ Date _______________Social Security # __________________Date of Birth _______________________DL # ___________________ AMARILLO PSYCHIATRIC ASSOCIATESHIPAA NOTICE OF PRIVACY PRACTICESFOR THE PRACTICES OFMURALI VEERAMACHANENI, M.D. P.A.RUBEN MENDOZA, M.D. P.A.BARBARA NEFSTEAD, N.P.22 CARE CIRCLEAMARILLO, TX 79124THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLYTHIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW WE MAY USE AND DISCLOSE YOUR HEALTH (PHI) PROTECTED INFORATION TO CARRY OUT TREATMENT, PAYMENT, OR HEALTH CARE OPERATION (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 INFORMATON ABOUT YOU, INCLUDING DEMOGRAPHING INFORMATION THAT MAY IDENTIFY YOU AND THAT RELATES TO YOUR PAST, PRESENT, OR FUTURE PHYSICAL OR MENTAL HEALTH OR CONDITION RELATED TO HEALTH CARE SERVICES.USES AND DISCLOSURE 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 USES 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 INFORMATION AS NECESSARY TO ANOTHER PHYSICIAN OR THERAPIST TO WHOM YOU HAVE BEEN REFERRED TO ENSURE THAT THE PHYSICIAN OR THERAPIST HAS THE NECESSARY INFORMATION TO DISCLOSE YOUR INFORMATION TO DIAGNOS AND TREAT YOU.AMARILLO PSYCHIATRIC ASSOCIATESHIPAA NOTICE OF PRIVACY PRACTICESFOR THE PRACTICES OFMURALI VEERAMACHANENI, M.D. P.A.RUBEN MENDOZA, M.D. P.A.BARBARA NEFSTEAD, N.P.22 CARE CIRCLEAMARILLO, TX 79124PAYMENT: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 OR VISITS WITH THE PSYCHIATRIST MAY REQUIRE THAT YOUR RELEVANT PROTECTED HEALTH INFORMATION BE DISCLOSED TO THE HEALTH PLAN TO OBTAIN APPROVAL FOR THE HOSPITAL ADMISSION AND/OR AUTHORIZATION VISIT WITH THE PSYCHIATRIST. HEALTHCARE OPERATIONS:WE MAY USE OR DISCLOSE, AS NEEDED, YOUR PROTECTED HEALTH INFORMATON TO SUPPORT THE BUSINESS ACTIVITIES OF YOUR PHYSICIAN’S PRACTICE. THESE ACTIVITIES INCLUDE, BUT ARE NOT LIMITED TO, QUALITY ASSESSMENT ACTIVITIES, EMPLOYEE REVIEW ACTIVITES, AND TRAINING OF MEDICAL STUDENTS, LICENSING, AND CONDUCTING OR ARRANGING FOR OTHER BUSINESS ACTIVITIES. WE MAY CALL YOU BY NAME IN THE WAITING ROOM WHEN YOUR PHYSICIAN IS READY TO SEE YOU. WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATON, AS NECESSARY, TO CONTACT YOU REGARDING YOUR APPOINTMENTS AND PAYMENTS.WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION IN THE FOLLOWING SITUATIONS WITHOUT YOUR AUTHORIZATION. THESE SITUATIONS INCLUDE: AS REQUIRED BY LAW, PUBLIC HEALTH ISSUES AS REQUIRED BY LAW, COMMUNICABLE DISEASES: HEALTH OVERSIGHT, ABUSE OR NEGLECT: FOOD AND DRUG ADMINISTRATION: LEGAL PROCEEDINGS: LAW ENFORCMENT: CORONORS, FUNERAL DIRECTORS, AND ORGAN DOATIONS: RESEARCH: CRIMINAL ACTIVITY: MILITARY ACTIVITY AND NATIONAL SERVICES: WORKER’S COMPENSATION: INMATES: REQUIRED USES AND DISCLOSURE: UNDER THE LAW, WE UST 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 REQUIRMENTS OF SECTION 164.500.AMARILLO PSYCHIATRIC ASSOCIATESHIPAA NOTICE OF PRIVACY PRACTICESFOR THE PRACTICES OFMURALI VEERAMACHANENI, M.D. P.A.RUBEN MENDOZA, M.D. P.A.BARBARA NEFSTEAD, N.P.22 CARE CIRCLEAMARILLO, TX 79124OTHER PERMITTED AND REQUIRED USES OF 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 PRACTICE HAS TAKEN AN ACTION IN RELIANCE ON THE USE OR DISCLOSURE INDICATED 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: PSYCHIATRIST NOTES, PSYCHOTHERAPY NOTES AND ANY OTHER MENTAL HEALTH INFORMATION COMPLIED IN REASONABLE ANTICIPATION OF, OR USE IN, A CIVIL, CRIMINAL, OR ADMINISTRATIVE ACTION OR PROCEEDINGS, AND PROTECTED HEALTH INFORMATION THAT IS SUBJECT TO LAW THAT PROHIBITS ACCESS TO PROTECTED HEALTH INFORMATION.YOU HAVE A RIGHT TO REQUEST A RESTRICTION TO YOUR PROTCTED HEALTH INFORMATION: THIS MEANS YOU MAY ASK US NOT TO USE OR DISCLOSE ANY PART OF YOUR PROTECTED HEALTH INFORMATION FOR 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, OR WHO MAY NOT BE INVOLVED IN YOUR CARE OR FOR NOTIFICATION PURPOSES AS DESCRIBED IN THIS NOTICE OF PRIVACY PRACTICES. YOUR REQUEST MUST STATE THE SPECIFIC RESTRICTIONS 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 THE PHYSICIAN BELIEVES IT IS IN YOUR BEST INTEREST TO PERMIT USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION. YOU HAVE THE RIGHT TO USE ANOTHER HEALTHCARE PROFFESIONAL.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 ALTERANTIVELY, I.E. ELECTRONICALLY.AMARILLO PSYCHIATRIC ASSOCIATESHIPAA NOTICE OF PRIVACY PRACTICESFOR THE PRACTICES OFMURALI VEERAMACHANENI, M.D. P.A.RUBEN MENDOZA, M.D. P.A.BARBARA NEFSTEAD, N.P.22 CARE CIRCLEAMARILLO, TX 79124YOU HAVE THE RIGHT TO HAVE YOUR PHYSICIAN AMEND YOUR PROTECTED HEALTH INFORMATION. IF WE DENY YOUR REQUEST FOR AMMENDMENT, YOU HAVE THE RIGHT TO FILE A STATEMENT OF DISAGREEMENT WITH US AND WE MAY PREPARE A REBUTTAL TO YOUR STATEMENT AND WILL PROVIDE YOU WITH A COPY OF SUCH REBUTTAL.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 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 PLAINTS: YOU MAY COMPLAIN TO US OR THE SECRETARY OF HEALTH AND HUMAN SERVICES IF YOU BELIEVE YOUR PRIVACY HAS BEEN VIOLATED BY US. YOU MAY FILE A COMPLAINT WITH US BY NOTIFYING OUR PRIVACY CONTACT. WE WILL NOT RETALIATE AGAINST YOU FOR FILING A COMPLAINT.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 OBJECTONS TO THIS FORM, PLEASE ASK TO SPEAK TO OUR HIPAA COMPLIANCE OFFICER IN PERSON OR BY PHONE.THIS NOTICE BECOMES EFFECTIVE ON SEPTEMBER 30, 2014.HIPAA COMPLIANCE OFFICER:DR. MURALI VEERAMACHANENI FOR THIS PRACTICEADDRESS: 22 CARE CIRCLE PHONE:806-354-8300 AMARILLO, TX 79124 FAX: 806-354-9962PRINT NAME OF PATIENT/GAURDIAN: ______________________________________________________SIGNATURE OF PATIENT/GUARDIAN: _______________________________________________________DATE: _____/______/______ ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download