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B. Dixit, M.D.Board Certified Psychiatrist 700 Center Street, Suite 202Columbus, GA 31901Telephone (706)327-5066WELCOME This letter is organized to answer questions you may have regarding your psychiatric care. Our office staff works together as a team. We take great pride in our training, capabilities, and knowledge and want you to know that we are dedicated to giving your quality psychiatric care.OFFICE HOURSRegular office hours are 9:00am to 5:30pm, Monday through Friday. We will try to see you at the scheduled time. We believe strongly in the value of your time and try our best to keep you from having to wait a long time. At times Dr. Dixit may be delayed due to emergency admissions and/or emergency situations that can delay your appointment time. In addition, with managed care, Dr. Dixit may have to spend more time on the phone with managed care companies, completing treatment reports, or with some patients to provide the best possible care. We appreciate your understanding and patience if he should run behind scheduled appointment times. We require a with this 24 hours’ notice, which is noted on your appointment card, if you find it necessary to cancel your appointment. We will charge a $50.00 fee for failure to provide us 24-hour notice, which can not be bill to insurance company.TELEPHONE CALLSOur telephone calls are answered from 9:00am until 5:30pm Monday through Friday. Our employees have been instructed to handle all incoming calls. If you find it necessary to speak with the doctor after the above stated hours for emergency purposes the answering service will forward the message to the physician on call and at the earliest possible convenience the physician will return the call. Dr. Dixit rotates weekend with four other physicians. PRESCRIPTION REFILLSJust as we cannot treat an illness over the telephone, we cannot prescribe medications over the telephone. Medications will only be handled during regular office hours and only if you are currently under our care. We require a 48 WORKING HOURS notice for all prescription refill requests. If you need a prescription refill, have the name of the medication, the dosage, along with the pharmacy name & telephone number available when you call. Controlled substances cannot be called in. You must come in to the office to pick up a written prescription.FEES AND CARE We make every effort to keep the cost of your health care to a minimum. You can help by paying at the time of your visit. We do collect your deductible, co-payment & co- ins. in advance at the time you check in at the front desk. This is expected unless prior financial arrangements have been made between you and the doctor. For you convenience, we accept Visa and MasterCard. Additionally, as a courtesy to you, we will file with your insurance company. However, if for any reason you should disagree with your insurance statement, it will be your responsibility to contact your insurance company for research.INSURANCEIf you have insurance coverage, please understand that this is an agreement between you and your insurance company. You hare responsible for your bill regardless of the status of you insurance claim. We will be glad to submit your insurance claims for prompt reimbursement. When you have changes in you insurance coverage, it is your responsibility to notify our office staff, so we may correct the insurance information on your account. Received Copy:_____________________________ Signed & Date:____________________________B. Dixit, M.D., P.C.Professional Tower700 Center Street, Suite 202Columbus, GA 31901Phone 706-327-5066 Fax 706-327-0081CONSENT OF OUTPATIENT TREATMENTAND TELEMEDICINEPatient Name ____________________________________________________________________Date of Birth _______________________I hereby authorize my psychiatrist and all other professional staff members affiliated with Dr. Dixit to care for me in ways they judge are beneficial to me. I understand that this care may include test, examinations, medications, medical, and psychiatric care will be fully explained to me and that I have the option to accept or reject such care.I also certify that I have received a copy of my rights as an outpatient of Dr. Dixit.I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the result of treatments and examination by Dr. Dixit. Comments:________________________________________________________________________________Signature:______________________________________________Date:_______________________________Witness:_________________________________________B. Dixit M.D., P.C.Professional Tower700 Center Street, Suite 202Columbus, GA 31901Phone 706-327-5066 Fax 706-327-0081HIPPA NOTICE of PRIVACY PRACTICES ACKNOWLEDGMENET OF RECEIPTI__________________________________________,___________________________have been given copy(Patient Name) (Date of Birth)Of the offices brochure of Privacy Practices.____________________________________ ______________________________ (Patient Signature) (Date)Authorization for Family, Friends or Advisors to Receive Information About Your Psychiatric/Alcohol/Drug condition or the status of your bill.I authorize the following individual/s to receive written and/or oral communications about my psychiatric/alcohol/drug condition, care , appointments, and that status of my bill. I understand that they will need to be able to provide the last four digits of my social security number for oral communication. If they should come to pick up a prescription, or to discuss my care or the status of my bill, they will need to bring a photo ID.Please Initial__________In the event you wish to remove any of the names listed below please come to the office in person to withdraw the release of information.Authorized Individual/s Relationship Phone Number __________________________ _____________________________ ________________________________________________________ _____________________________ ______________________________ __________________________ _____________________________ ______________________________ _______________________________________ _____________________________________________ (Patients Signature) (Date)________________________________________________________PRINT NAME: B. DIXIT M.D. PROFESSIONAL TOWER 700 CENTER STREET STE. 202 COLUMBUS GA 31901 PLEASE PRINT!Date:_______/_______/________Patient’s Name__________________________________________________________S.S.N.:_______________________________________________736600081915Mailing Address: ______________________________________________________________________________________________________________City______________________________________________________State__________________________Zip______________ - ____________________Home Phone_________________________________Cell Phone____________________________Work Phone____________________________Email address__________________________________________________________________________________________________________________308610015875339288912065Age____________Date of Birth___________________Sex M F , S.S.N.________________________________________________________324866037465 417703042545 544512543180 157863532888 00 231775031750Marital Status : Married Divorced Separated Widowed Never Married 832421574930Spouse’s Name________________________________________DOB:______________________SSN_________________________________________Spouse’s Occupation:________________________________ Spouse’s Contact Information________________________________________Number of marriages/divorces______________________________________________________________________________________________Patient’s Race(Optionial) Circle one:Caucasian/White, African American/Black, Hispanic, Asian, Native American, Multi-RacialOther(Specify_______________)Religion _____________________ Living situation: How many people are in your house hold? ______________________ Children (include age/sex)_________________________________________________________________________________________________Relationship with children: _________________________________________________________________________________________________Mother_______________________Age_________ Father_________________________Age_______Living?____________Deceased?_____________ Living?_____________Deceased?___________Describe Relationship:____________________ Describe Relationship:_________________________________________________________________ _____________________________________________Number of sisters: _______, Age _______________ Number of Brothers: ___________ , _________________ B. DIXIT M.D. PROFESSIONAL TOWER 700 CENTER STREET STE. 202 COLUMBUS GA 31901 Please list 2 people outside of your immediate family that we could contact in case of an emergency:_____________________________________________________________Phone________________________________________________________________________________________________Phone___________________________________ B. DIXIT M.D. PROFESSIONAL TOWER 700 CENTER STREET STE 202 COLUMBUS, GA 31901PATIENT NAME: _______________________________________________________Family Physician:_______________________________________________Phone#______________________________________________________Referring Physician:_________________________________________Phone#_________________________________________________________386969017780 347069522860 Are you currently seeing a Counselor or Therapist? YES NO If Yes, name of Counselor or Therapist _______________________________Phone#_______________________________________________When did you begin to see this Counselor or Therapist? _____/______/_____How often do you see this Counselor or Therapist?__________________________________________________________________________Preferred Pharmacy(Local):_____________________________________________Phone#______________________________________________Mail Order Pharmacy:________________________________________Phone#_______________________________________________________________________FAX #_____________________________________________RX ID#_______________________________________________________________________Primary Insurance________________________________________________________________________________________________________________________ID# ___________________________________Group#__________________________________________________________________________________Subscribers Name:_______________________________Relationship To Patient:__________________________________________________Subscribers DOB:_______________________________Subscribers SSN____________________________________________________________Secondary Insurance__________________________________________________________________________________________________________ID#___________________________________Group #__________________________________________________________________________________Subscribers Name:_______________________________Relationship to Patient:____________________________________________________Subscribers DOB:_______________________________Subscribers SSN______________________________________________________________ B. DIXIT M.D.700 CENTER STREET, STE 202COLUMBUS, GA 31904Signature on fileInsurance InformationPATIENT NAME: __________________________________________________________________________PLEASE READ THE FOLLOWING STATEMENTS AND INITIAL ON EACH LINE________I AUTHORIZE USE OF THIS FORM ON ALL MY INSURANCE SUBMISSIONS________ I AUTHORIZE RELEASE OF INFORMATION TO ALL MY INSURANCE COMPANIES________I UNDERSTAND THAT I AM RESPONSIBLE FOR MY BILL________I AUTHORIZE MY DOCTOR TO ACT AS MY AGENT IN OBTAINING PAYMENT FROM MY INSURANCE COMPANY________ I AUTHORIZE PAYMENT DIRECTLY TO MY DOCTOR________I PERMIT A COPY OF THIS AUTHORIZTION TO BE USED IN PLACE OF THE ORIGINAL________I AUTHROIZE THE OFFICE TO CALL ME TO REMIND ME OF APPOINTMENTS________I AUTHORIZE THAT IT IS OKAY TO LEAVE A MESSAGE WITH SOMEONE AT MY NUMBER OR ON A ANSWERING MACHINE________ IT IS OKAY TO CALL ME AT WORK TO REMIND ME OF APPOINTMENTS________ I AUTHORIZE THE OFFICE TO REMIND ME OF APPOINTMENT VIA EMAIL AND TEXT MESSAGE. PLEASE READ THE INFORMATION BELOWI understand that I am responsible for checking with my insurance company regarding any contract requirements for outpatient treatment. I am also responsible for obtaining any referrals required by my insurance for office visits. I authorize any holder of medical records or other information about me to release to my insurance company or to the social security administration and healthcare financing administration or its intermediaries or carrier any information needed for this or a related insurance claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to either myself or the party who accepts the agreement. Regulars pertaining to medical assignment of benefits apply.I hereby authorize payment to Dr. B. Dixit M.D. for services rendered. I understand that I am responsible and do agree to pay any balance unpaid by my insurance company. ________________________________________________________________________________________________________________________________Signature of PatientDate_______________________________________________________________________( Print full Name)B. DIXIT M.D.700 CENTER STREET, STE 202COUMBUS, GA 31901PATEINT NAME:_____________________________________________________________________Who referred you to my office?1225554291600 Mental Health Provider ___________________________________________________1177393111500 Physician/Primary Care Provider ____________________________________________1305464508500 Emergency Room1381664254500 I decided to seek Treatment1584863175000 __ Inpatient Psychiatric UnitMedical History:YESNODescribe147320029210188456126335Serious Accidents ______________________________________________________________________________________________147383563236187960056251Hospitalizations/surgery_______________________________________________147727426670188722033284Allergies______________________________________________________________________________________________146139910160189927315911Negative Reaction_______________________________________________To Medications_______________________________________________146912645720190944555509Major Illnesses_________________________________________________________________________________________________1465951508019062706350Previous Medications__________________________________________________________________________________________________1446266-12701902820-4146Current Medications_________________________________________________(Include dose)__________________________________________________________________________________________________Immunizations up-to-date? Yes No583882524130532574526035Does your family have a history of health problems (e.g., diabetes, high blood pressure)? Yes NoIf yes, who and what?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________Has anyone in your family had mental health problems like depression, anxiety, psychosis, dementia?7000822707837745433020 Yes No If yes, who and what? _________________________________________________________________________________509502536195463042027940Has anyone in your family every committed suicide or had a suicide attempt? Yes NoIf yes, please describe___________________________________________________________________________________________________________________________________________________________________________________________________________________________________216598529881179006525400Are you sexually active? Yes No _________________________________________________________________________________B. DIXIT M.D.700 CENTER STREET, STE 202COLUMBUS GA 31904PATIENT NAME: _________________________________________________________________________Current source of stress (such as job changes, moves, deaths, financial problems)?______________________________________________________________________________________________________________________Have you ever been involved in any of the following?DUI (how many)_____________ Bad Checks_____________ Drunk/Disorderly_____________________________Sexual Abuse________________ Assault________________ Theft_____________________________________________Legal Problems______________ Picked up by the police______________________________________________________Possession/Use of drugs______________________________ Other(be specific)_____________________________What do you do for fun/relaxation?____________________________________________________________________________________Have you noticed you have problems with:294322534290-15621031115Sadness almost all day nearly every day Suicidal thoughts or behaviors293459934290-15938531115Loss of interest in activities Other self-injury behaviors_______________________________294322540005-15303531115Sleep Problems Substance abuse___________________________________________294263849530-15303550800Appetite Problems Significant fears/worries294037448895-15621033020Significant weight loss/gain Nightmares or sleep walking 294587331115-15303530480Fatigue/tired a lot Hyperactivity294354941275-15303542545Feeling guilty Poor attention/concentration293946341275-1593855080Poor self-esteem/feel worthless Impulsive behavior294582538471-16166138735Very agitated/irritable Poor behavior293820525400-15557538735Long crying spells Hallucinations (seeing/hearing things others don’t)29393684445-15875038735Withdrawn Unusual behaviors_____________________________________Please describe any that you have checked above: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________248412019722293453931750Have you hurt yourself in any way? Yes NoIf yes, how?______________________________________________________________________________________________________________________B. Dixit M. D.700 Center Street STE 202Columbus, GA 31901PATIENT NAME: ___________________________________________________________________Have you ever made any of the following or similar comments? Please check all that apply.-9106925400 “I wish I were dead.” -10033024130 “ I wish I could go to sleep and never wake up.”-9498653975 “I wish I could get in the car and keep going and never come back.”Have you ever given away a prized possession? Yes No If yes please list:_____________________________________________________________________________________________________________________________________________________________Have you ever threatened to harm another person? Yes No If yes please explain:____________________________________________________________________________________________________________________________________________________________Have you ever used any of the following drugs? How often and Last time used Current problem? How muchCigarettes__________________________ _____________________ ___________________Alcohol __________________________ _____________________ ___________________Crack/Cocaine __________________________ ______________________ __________________Diet Pills __________________________ _____________________ __________________Marijuana __________________________ _____________________ __________________Other __________________________ _____________________ __________________Problem(s) or special concern that brought you here today:________________________________________________________________________________________________________________________________________________________________________________________List previous psychiatric treatment (outpatient and inpatient). Please state name of hospitals, doctors, length of illness, and result of treatment: _________________________________________________________________________________________________________________________________________________________________________________________________________________________What concerns you most at this time?___________________________________________________________________________________________________________________________________________________________________________________________________________________What are you hoping to accomplish by coming to my office? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Any additional information that would be helpful for us to know?___________________________________________________________________________________________________________________________________________________________________________________ B. Dixit M.D. P. C. 700 Center Street STE 202 Columbus, GA 3101Policies and ProceduresCONFIDENTIALITYAll communications between the patient and Dr. Dixit or his Associates will be held in confidence, and will not be revealed to anyone unless you give written authorization to release this information. Georgia law requires that confidentiality be waived with the patient’s or other’s personal safety is threatened or when disclosures of child abuse are made to the therapists. If it is necessary to contact you at home or work, we will be discrete. We request that you complete a Release of Information form so that we may be in contact with your personal physician. Information routinely release to insurance companies for reimbursement for services shows only a diagnosis, the dates of service, charges, and payments. In order to file your insurance, it is necessary for you to sign a Release of Information form. APPOINTMENTSWe will try to see every patient at their scheduled time. However, emergencies do arise and the Doctor does see patients at the hospital and may arrive late, we ask that you please be considerate should this situation arise. Please bring list of your current medicine and bottles every visit. If you got your blood work at your primary care physician’s office be sure to bring your copy of lab results for Dr. Dixit to review and keep them in your chart.No show or cancellation of appointment without a 24-hour notice will be charged minimum $50.00 fee or as high as your co pay or coins, whichever is higher. This fee is not billable to your insurance company. 3 no shows may result in dismissal from practice. Returned checks will incur $35.00 fee from our office Plus bank charge. We use The ChecXchange electronic service for returned check or non-sufficient amount there will be a separate charge for their service in the event your check is returned.If we have to send statement for your balance of amount there will be a $5.00 service charge will be added to your bill each billing cycle.RESCRIPTION REQUESTLost Prescription: there will be $20.00 charge to re-write the script.No-show for schedule appointment medicine may not be called in to pharmacy till. You have Been SEEN. PAPERWORK and LETTERThere will be a minimum fee of $25.00 charge any paperwork to be filled. If there are more than two pages fee will be $ 50.00 or as high as $100.00. This fee will need to be pre-paid prior to completion of LETTER OR PAPERWORK.Sincerely,Dr. Dixit’s StaffPatient’s Signature_____________________________________________________Date_______________________ ................
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