Alison Shapiro, PMHNP-BC - Achieve Whole Recovery
Alison Shapiro, PMHNP-BC 1115 Elkton Drive, suite 300Colorado Springs, CO 80907Office - 1-719-373-9703 Fax - 1-877-588-3465 HYPERLINK "" Patient Last Name: ____________________ First: ____________ DOB: _______ today’s Date: _______ADULT PERSONAL HISTORYPLEASE ANSWER EACH QUESTION FULLY. If you need more space, please go to form end.1. Name and relationship of person providing information, if not self:Patient’s gender: □ MALE □FEMALEMedication Allergies: If none, so state. 2. Patient’s physician’s name, telephone number and address:3. Current or past therapist name and telephone number:4. What agency or individual referred you? Name and phone number, please.5. How can I try to help? When did things start to be a problem? What has helped? What hasn’t helped? What are your strengths?6. Past medical history of the patient: (high blood pressure, diabetes, head trauma, etc). If none, so state.7. Past or current psychiatric care: For what, where, hospitalizations, medications, suicide attempts, danger to others: If none, so state.8. Have you been the victim of trauma such as war or abuse? If yes, please try to outline.9. Family medical history: (high blood pressure, diabetes; who?) If none, so state.10. Family psychiatric and substance/alcohol abuse history: (depression, drug/alcohol; who?) If none, so state.11. Current Medications, Over-The-Counter Medications and Dosages: If none, so state.12. Current or Significant Past Substance Use: (If none, so state).Alcohol intake per week:Caffeine use per dayRecreational drug use:Tobacco/Nicotine Use:Marijuana use (include MMJ):13. Social History:Who lives at home with you?Your occupation?How would you describe your growing up years? What was good? What wasn’t?What are your hobbies; educational/recreational/personal interests?14. Is there or has there been involvement of legal, court, or social services with you or your family? If none, so state. Any financial difficulties? If none, so state. If yes, describe.15. Education:Highest grade achieved: _____________________Please describe any special education classes, IEP, 504, or any IQ or psychological testing: If none, write “none”.Please describe any learning difficulties. If none, write “none”. ____________________________________Please use below to explain anything further, using the above question numbers to indicate which information you are providing.PATIENT REGISTRATION FORMMarital Status __________Gender: ________Home Address_______________________ City ________________________State___ Zip ________ Home Phone ________________________________Ok to call? Y/N ____ Leave message Y/N _____ Work Phone ________________________________Ok to call? Y/N ____ Leave message Y/N ______ Cell Phone _________________________________ Ok to call? Y/N ____ Leave message Y/N _____ Email (of adult patient or parent)____________________________________ OK to use? Y/N _____Parents names of minor patient, or for adult patient with legal guardian, guardian’s name:_____________________________________________________________________________________Financially Responsible Party Name _________________________________SSN ___________________Address and phone numbers if different from above:__________________________________________If patient is child, mother’s name ___________________________Address as patient? Y/N _____ If not, Address ______________________________City_______________________ State ____ Zip _________ Home Phone: ______________ Work Phone: ________________ Cell: ___________________If patient is child, father’s name ___________________________Address as patient? Y/N _____ If not, Address ______________________________City_______________________ State ____ Zip _________ Home Phone: ______________ Work Phone: ________________ Cell: ___________________Patient’s Insurance ________________Group Number_______________ID Number ________________Sponsor Name _____________________ Sponsor SSN _______________Sponsor DOB ____________Sponsor Relationship to Patient: self / parent / spouse / other _____________________Sponsor Address ___________________________________City/State _________________ Zip ______CONSENT TO TREATMENTThank you for choosing treatment with Alison Shapiro, PMHNP-BC. We believe it is important for you to understand your rights and responsibilities as patients and supportive family members. Your signature on this form provides consent for treatment, payment, and acknowledges receipt of other general information. If you have questions, please contact us at 719-309-8581. Consent for TreatmentI consent to and authorize the attending physician, physician’s assistant, nurse practitioner, referring providers and others of the healthcare team, including providers in training, and students in other disciplines-to perform healthcare examinations, treatment, diagnostic testing, transfers and transportation as deemed medically necessary in their professional judgment.Privacy, Confidentiality and Safety: Personal information shared with us during our sessions is confidential and not shared with anyone without a signed release of information, except under specific legal and safety concerns as defined by laws.? If there is an indication of child abuse, risk of danger to self, or risk of danger to others, we are legally bound to report the concerns to the appropriate authorities. As noted above, communication with your other care providers including your family doctor, therapist, or other clinicians is strongly recommended for the best possible treatment outcome.? Please provide their contact information and your consent to communicate with them.? Only essential and pertinent medical will be shared with your providers in accordance with privacy laws.? Your signed consent is necessary for us to be able to communicate with them.Assignment of Benefits and Release of InformationI agree to be responsible for my co-payments, deductibles or other charges from Alison Shapiro, PMHNP-BC and of providers rendering services not covered or paid by insurance or other third-party payers-except as prohibited by any agreement between my insurance company and Alison Shapiro, PMHNP-BC or by state or federal law.I authorize Alison Shapiro, PMHNP-BC to file any claims for payment of any portion of the patient bills and assign all rights and benefits payable for provider services to the provider or organization furnishing the services.I further agree, subject to state or federal law, to pay all costs, attorney fees, expenses, delinquent charges and interest in the event Alison Shapiro, PMHNP-BC has to take action to collect same because of my failure to pay in full all incurred charges within 60 days after the receipt of the bill.The term of this consent will be until final payments are made for any and all services.If and when there are changes to my insurance plans, I will notify Alison Shapiro, PMHNP-BC staff immediately.Cancellation and Late Policy__I agree that:If I do not show up, or cancel my appointment with less than 24 hours notice that I will be billed $75.00.If I do not show up for an appt or cancel late 2 or more times that I will be rescheduled and considered a late cancel.If I arrive more than 10 minutes late for an appointment that it will be rescheduled and considered a late cancel.Billing Policy__I agree that:If I have an outstanding balance, I will be required to pay this balance in full before scheduling any future appointments and will help Alison Shapiro, PMHNP-BC to resolve any issues with my insurance company.I will be charged $50 per 10 minutes of time that is used to address issues that occur outside of session such as letter or report writing and telephone calls of clinical importance (non-scheduling related). General Information__I understand:Alison Shapiro, PMHNP-BC may prescribe medication and require that the patient takes the medication as recommended.The first appointment is approximately one hour. All subsequent “follow-up” visits are intended to provide a brief checkup on the patient’s status and to adjust or refill prescriptions. I will review the number of pills the patient has left before coming to the office.Alison Shapiro, PMHNP-BC will give me a list of recommended therapists if they feel it is appropriate, which they expect the patient to see on a regular basis.Alison Shapiro, PMHNP-BC will check the PDMP (Prescription Drug Monitoring Program) on a regular basis if you are prescribed a controlled substance.If, after a prescription has already been written and sent to a pharmacy, it may take up to 24 hours to change the pharmacy location if you request your prescription to be sent to a new location. Notice of Privacy Practices__I acknowledge that I have been offered and/or received the receipt of Alison Shapiro, PMHNP-BC “Notice of Privacy Practices” brochure_________________________________ ___________________________________Print Patient’s Name Guardian’s Printed Name/Relationship (if applicable)_________________________________ ___________________________________Date Patient or Guardian SignatureAlison Shapiro, PMHNP-BC Authorization to Use and Disclose Health InformationIdentifying Information ______________________________________Client Name ___________Date of Birth RELEASE FROM AND TO:I authorize information about the above referenced participant to be exchanged between Alison Shapiro, PMHNP-BC/Achieve Whole Recovery and the following System of Care User Group agencies, individuals, or programs as listed below (Include fax number to ensure that information is transmitted to the correct party). Please notate below if you would only like Alison Shapiro, PMHNP-BC/Achieve Whole Recovery to receive collateral information from an individual/business (as opposed to exchanging information between parties)**I understand that information disclosed may be written, verbal or electronic form and may include date(s) of contact, locations and reasons for contact, symptoms presented, treatment progress, outcome information, prescriptions, written referrals, educational records, medical records, tests performed, and/or diagnosis. I understand that disclosure may include: psychological/psychiatric; medical; shelter and case management; and/or alcoholism, drug and/or alcohol abuse information. Information to be released may include information regarding the following.I understand that the purpose of this information disclosure is to allow the participating entities (identified above) to access and use the information to establish and maintain continuity of care, better assess the effectiveness of the program, and/or to improve their services based on service utilization studies.I understand that I may refuse to sign this authorization, and no one is conditioning treatment, payment, enrollment or eligibility for benefits on signing this authorization. I understand that there is potential for information disclosed, as a result of this authorization, to be re-disclosed by the recipient and therefore no longer protected by the HIPAA Privacy Regulations. When applicable, an assessment of the minimum necessary amount of information required has been applied to this authorization.I understand that I may revoke this authorization, at any time, by giving written notice to the authorized System of Care User Group agencies or programs, except to the extent that action has already been taken to comply with it. Without such revocation this authorization will expire on, or if left blank, one year from my signature date.I understand that I am entitled to a copy of this authorization._________________ __________Signature DateCREDIT CARD AUTHORIZATION- ALISON SHAPIRO, PMHNPIn order to provide you and other patients of Alison Shapiro, PMHNP the best possible care, a minimum of 24 hours notice is required to cancel or reschedule your appointments. For example, cancel by 2pm twenty four hours in advance for a 2pm appointment on the following day. Cancellation must occur via phone call or email. I, ___________________________, understand the importance of notifying Alison Shapiro at least 24 hours prior to my scheduled appointment that I am not able to keep my appointment. If I am experiencing an emergency, I will provide as much notice as possible to avoid being charged the Late Cancellation fee of $75. I understand that I will be charged a No Show fee of $75 for failing to call and failing to show for my scheduled appointment. No Shows that occur for the Initial Evaluation will be charged $100. These fees will be charged automatically to my credit card as they occur. This form provides my permission to charge my credit card when a No Show or Late Cancellation occurs. I will be provided a receipt for all payments upon request. This card may also be used for payment of services upon my request (co-payment, deductibles, and fees). In addition, these fees must be paid before you can schedule a new appointment. I understand that I may revoke this agreement at any time by providing a request in writing. I am also aware that when psychological services rendered by Alison Shapiro, PMHNP end, this form shall be considered void. I am consenting that this card be used for payment of services (co-pay and fees)____YesName on Card__________________________________________Card Number___________________________________________Expiration Date_________________________________________3 digit code___________Street Address_____________________________Zip Code_________Email address for receipt_________________________________Patient Name (printed)__________________________________Patient/Card Holder Signature:___________________________________________________ Date__________________ ................
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