What New Patients Should Know About Sarkis Family Psychiatry:

Sarkis Family Psychiatry was started in 1991 by Elias Sarkis, MD. Since then, it has grown to include Nurse Practitioners, Mental Health Counselors, and Licensed Clinical Social Workers.

We are a group practice, which means we work closely together to provide evaluation, education and treatment for a whole range of mental disorders and emotional problems. As a result, you may see several of us in the course of your treatment. One of the great advantages of a group practice is the ease with which care can be coordinated and the ready availability of on-the-spot consultation. Because we recognize the importance of families and know that one family member’s problems have an effect on the entire family, we try to include the whole family in treatment, whenever possible.

HOURS:

Our office hours are: Monday through Thursday, 8:30 am to 6:00 pm and Friday, 9 am to 2 pm.

Telephone hours are: Monday through Thursday, 9am to 6:00 pm, and Friday 9 am to 2 pm.

Requests for prescription refills should be made during these times. We require 4 days notice to process refills, so please request refills prior to running out of medications.

APPOINTMENTS:

Initial visits are one hour long and are $325 to see a Physician or $250 to see a Nurse Practitioner or Psychologist. Follow-up appointments may be scheduled for 15 minutes up to 45 minutes, depending on your needs, the service being provided, and the individual practitioner.

You have the option to receive a courtesy confirmation call one day prior to any existing appointments. These calls are a courtesy only. You are responsible for your scheduled appointments and will be responsible for any fees incurred from missed or late arrivals, regardless of whether or not your appointment was confirmed.

PAYMENTS:

For your convenience, we accept cash, checks, Visa, MasterCard, American Express and Discover.

Our fees are based on time and skill, as well as overhead factors. It is our goal to provide you with the best possible services for the fees we charge. In order to keep our overhead as low as possible, we require payment of all fees at the time of service. If for any reason this is not possible, financial arrangements must be made prior to your visit.

Please Initial here stating that you understand our policy

FEES FOR MISSED APPOINTMENTS:

Missing an initial appointment = $325 or $250

Missing a follow-up appointment = $75

Once an appointment is scheduled, this time is reserved for you only. In order for us to see all of our clients at the scheduled time, it is extremely important that you arrive on time for your appointment. If you miss an appointment, you’ll need to reschedule. Note that refill requests may not be honored if follow-up appointments have not been kept. New patients who do not arrive on time or do not show for their initial appointment will be required to pay the full visit fee of $325 or $250 prior to rescheduling. This will be applied to the missed appointment, not to the rescheduled appointment.

An appointment will be considered “missed” in each of the following situations:
• You arrive more than 15 minutes late for your appointment.
• You cancel an appointment without sufficient notice (48 hours for the initial appointment, 24 hours for a follow-up).
• You don’t show for a scheduled appointment.

Please initial here stating that you understand our policy

OTHER FEES:

• Returned check = $50

• Interest applied to balances over 60 days = 1.5% per month.

• Telephone conferences between you and your provider = based on the length of the conversation.

• Letters and forms completed on your behalf = based on the length of the letter or forms.

Please initial here stating that you understand our policy

If this account is assigned to an attorney for collection, the prevailing party shall be entitled to reasonable attorney’s fees
and cost of collection. Please initial here stating that you understand our policy

 

I have read, initialed and understand Sarkis Family Psychiatry’s Office Policies explained in WHAT NEW PATIENTS SHOULD KNOW ABOUT SARKIS FAMILY PSYCHIATRY.

Patient Signature: Date:

Guardian Signature: Date:

NEW PATIENT INFORMATION SHEET:

Please complete all information on the enclosed forms and if possible send a copy of the front and back of your insurance
card so that your coverage can be verified. Please return this packet as soon as possible.

Patient’s Name: Last: First: MI:

Sex: Male Female Date of Birth: SSN:

Address: Apt/Suite:

City: State: ZIP Code:

Home Phone #: Alternate Phone #:

Email Address:

Patient’s Information: Employed Student Employer/School:

Work Phone #: (Give only if we may contact you at work)

Courtesy Confirmation call #:

Emergency Contact Name: Emergency Phone #:

Referring Doctor(s):

If patient is a minor of divorced parents or has a legal guardian that is not a biological parent, please provide custody/guardianship agreement pertaining to medical and mental health treatment.

Guardian’s Name: Guardian’s Phone #:

Guardian’s Address:

INSURANCE ASSIGNMENTS & AUTHORIZATION:

If you do not have insurance or you do not wish to use insurance, please initial here and skip this page

We are OUT-OF-NETWORK with all insurance companies. As a courtesy we will file most insurances for you. You will
need to pay for the full fee at the time of service. If your plan provides out-of-network benefits, your insurance
company will usually send the reimbursement check to you, depending on your plan. If we receive the check,
we will apply it as a credit to your account.

Please initial here stating that you understand our policy

1. RELEASE OF INFORMATION: I, the below named patient or guardian, do hereby authorize any physician examining and/or treating me to release to third party payer any medical, psychiatric condition, alcohol or drug related condition and records concerning diagnosis and treatment when requested by such third party for its use in connection with determining a claim for payment for such treatment and/or diagnosis.

2. PHYSICIAN INSURANCE ASSIGNMENT: I, the below named subscriber, hereby authorize payment directly of medical benefits to the physician examining or treating me herein specified and otherwise payable to me for their services as described, but not to exceed the reasonable and customary charges for these services.

3. I PERMIT A COPY OF THIS AUTHORIZATION AND ASSIGNMENT TO BE USED IN PLACE OF THE ORIGINAL THAT IS ON FILE AT THE PHYSICIAN’S OFFICE. This assignment will remain in effect until revoked by me in writing.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge.

 

INSURANCE INFORMATION:

If possible send us a copy of the front and back of your insurance card so that we may verify your coverage.

Insurance Company: Phone #:

Mailing Address:

City: State: Zip Code:

Policy Dates: From: To:

Member (Contract) ID: Group #:

Policy Holder’s Information:

Name: Relationship to Patient:

Sex: Male Female Date of Birth: Phone #:

Address:

City: State: Zip Code:

Insured’s Employer:

 

I have read and understand Sarkis Family Psychiatry’s Policies about insurance explained in the WHAT NEW PATIENTS NEED TO KNOW ABOUT SARKIS FAMILY PSYCHIATRY.

Please electronically sign your name below; you will also be required to sign in person upon your first visit.

Patient’s Signature: Date:

Guardian’s Signature: Date:

Adult or Child Questionnaires:

* Please be sure to fill out the proper Questionnaire below.

Select One:



Adult Questionnaire (18+)

Name: Date of Birth: Date:

Place a check next to any of the following that have been a significant problem for you during the past month.

We also have clinical trials for treatment of many common conditions such as Attention Deficit Disorder, Depression, Bipolar disorder and Anxiety Disorders. These research programs help with the advancement of treatment options and you may be eligible for compensation for your time and participation.

Would you be interested in being contacted about clinical trials for which you might be eligible?

Yes

No

Difficulty with getting things organized

Frequent procrastination of important tasks

Forgetting important tasks

Being easily distracted by noise or activity around you

Feeling restless of fidgety

Feeling easily bored

Irritability or impatience

Worrying too much

Muscle tension

Feeling easily overwhelmed

Feeling sad or down

Lack of pleasure in activities

Fatigue and/or low energy

Difficulty falling asleep

Difficulty staying asleep

Low self-worth

Guilt

Anxiety attacks and/or panic attacks

Feeling that your mind is moving too fast

Acting impulsively

Intrusive thoughts about traumatic experiences

Feeling embarrassed too easily

Other problems (describe):

Describe the problem(s) you most want us to help you with:

List any medications you are currently being prescribed:

Name of medication: What is your current
dose of this
medication?
How often do you
take this medication?
How long has this
medication been
prescribed for you?
Who prescribes this
medication for you?

List any recent surgeries, illnesses, or hospitalizations:

Are you interested in seeing a specific clinician? If so, please list the clinician's name.

How did you hear about our clinic?

If another clinician referred you or recommended you to us, please tell us their name.

Are you being treated by another mental health clinician?




Child & Adolescent Questionnaire (Under 18 yrs)

Name: Date of Birth: Date:

Place a check next to any of the following that have been a significant problem for your child during the past month.

We also have clinical trials for treatment of many common conditions such as Attention Deficit Disorder, Depression, Bipolar disorder and Anxiety Disorders. These research programs help with the advancement of treatment options and you may be eligible for compensation for your time and participation.

Would you be interested in being contacted about clinical trials for which you might be eligible?

Yes

No

Difficulty with getting things organized

Frequent procrastination of important tasks

Forgetfulness

Being easily distracted by noise or activity around them

Being overly restless of fidgety

Getting easily bored

Irritability or impatience

Meltdowns and/or temper tantrums

Aggressive behavior

Worrying too much

Fear of being separated from you

Other fears

Refusing to go to school

Complaining about stomach pain

Appearing sad or down

Not enjoying their usual activities

Fatigue and/or low energy

Difficulty falling asleep

Difficulty staying asleep

Wanting to sleep too much

Low self-worth

Anxiety attacks and/or panic attacks

Talking too fast

Acting impulsively

Poor grades in school

Behavioral problems at school

Other problems (describe):

Describe the problem(s) you most want us to help your child with:

List any medications your child is currently being prescribed:

List any recent surgeries, illnesses, or hospitalizations:

Are you interested in seeing a specific clinician? If so, please list the clinician’s name.

How did you hear about our clinic?

If another clinician referred you or recommended you to us, please tell us their name.

Is your child being treated by another mental health clinician?

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.

UNDERSTANDING YOUR HEALTH RECORD

A record is made each time you visit a hospital, physician, or other health care provider. Your symptoms, examination and test results, diagnosis, treatment, and a plan for future care are recorded. This information is most often referred to as your “health record” or “medical record,” and serves as a basis for planning your care and treatment. It also serves as a means of communication among any and all other health professionals who may contribute to your care. Understanding what information is retained in your record and how that information may be used, will help you to ensure its accuracy and enable you to relate to who, what, when, where, and why others may be allowed access to your health information. This effort is being made to assist
you in making informed decisions before authorizing the disclosure of your medical information to others.

UNDERSTANDING YOUR HEALTH INFORMATION RIGHTS

Your health record is the physical property of the health care practitioner or facility that compiled it, but the content is about you, and therefore, belongs to you. You have the right to request restrictions on certain uses and disclosures of your information and to request amendments to your health record. Your rights include being able to review or obtain a paper copy of your health information and to be given an account of all disclosures. You may also request communications of your health information be made by alternative means or to alternative locations. Other than activity that has already occurred, you may revoke any further
authorizations to use or disclose your health information.

OUR RESPONSIBILITIES

This office is required to maintain the privacy of your health information and to provide you with notice of our legal commitment and privacy practices with respect to the information we collect and maintain about you. This office is required to abide by the terms of this notice and to notify you if we are unable to grant your requested restrictions or reasonable desires to communicate your health information by alternative means or to alternative locations. This office reserves to right to change its practices and effect new provisions that enhance the privacy standards of all patient medical information. In the event that changes are made, this office will notify you at the current address provided on your medical file. If applicable, this office will post changes on our web site that provides information about our customer service and/or benefits. Other than for reasons described in this notice, this office agrees not to use or disclose your health information without your authorization.

TO RECEIVE ADDITIONAL INFORMATION OR REPORT A PROBLEM

For further explanation of this notice, you may want to contact the Privacy Officer, Jorge Franceschi, at 333-0094. If you believe your privacy rights have been violated, you have to right to file a complaint with this office by contacting the individual above, or by contacting the Secretary of Health and Human Services, with no fear of retaliation by this office.

YOUR HEALTH INFORMATION WILL BE USED FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

Treatment – Information obtained by your health care practitioner in this office will be recorded in your medical record and used to determine the course of treatment that should work best for you. This consists of your physician recording his/her own expectations and those of others involved in providing your care, such as specialty physicians, nurse practitioners, or therapists.

Payment – Your health care information will be used in order to receive payment for services rendered by this office. A bill may be sent to either you or a third-party payer with accompanying documentation that identifies you, your diagnosis, procedures performed, and supplies used.

Health Care Operations – The medical staff in this office will use your health information to assess the care you received and the outcome of your case compared to others like it. Your information may be reviewed for risk management or quality improvement purposes in our efforts to continually improve the quality and effectiveness of the care and services we provide.

UNDERSTANDING OUR OFFICE POLICY FOR SPECIFIC DISCLOSURES

Business Associates – Some or all of your health information may be subject to disclosure through contracts for services to assist this office in providing health care. For example, it may be necessary to obtain specialized assistance to process certain laboratory tests or radiology images. To provide your health information, we require these Business Associates to follow the same standards held by this office through terms detailed in a written agreement.

Notification – Your health record may be used to notify or assist family members, personal representatives, or other persons responsible for your care to enhance your well-being or your whereabouts.

Communications with Family – Using best judgment, a family member or close personal friend identified by you may be given information relevant to your care and/or recovery.

Marketing – This office reserves the right to contact you with appointment reminders or information about treatment alternatives and other health-related benefits that may be appropriate to you.

Research – Your information will be disclosed to researchers, upon assurance that established protocol to ensure the privacy of your health information has been obtained. Staff may review records to determine eligibility for current studies at our site.

Food and Drug Administration (FDA) – This office is required by law to disclose health information to the FDA related to any adverse effects of food, supplements, products, or product defects for surveillance to enable product recalls, repairs, or replacements.

Worker’s Compensation – This office will release information to the extent authorized by law in matters of worker’s compensation.

Public Health – This office is required by law to disclose health information to public health and/or legal authorities charged with tracking reports of birth and morbidity. This office is further required by law to report communicable disease, injury, or disability.

Correctional Facilities – This office will release information on incarcerated individuals to correctional agents or institutions for the necessary welfare of the individual or for the health and safety of other individuals. The rights outlined in this Notice of Privacy Practices will not be extended to incarcerated individuals.

Law Enforcement – (1) Your health information will be disclosed for law enforcement purpose as required under state law or in response to a valid subpoena. (2) Provisions of federal law permit the disclosure of your health information to appropriate health oversight agencies, public health authorities, or attorneys in the event that a staff member or business associate of this office believes in good faith that there has been unlawful conduct or violations of professional or clinical standards that may endanger one or more patients, workers, or the general public.

RESPECT OTHER PATIENT’S PRIVACY

If you are found accessing another patient’s medical record or any other documents with personal health information without the consent of the patient and permission from the facility, you will be asked to leave the clinic and not return.

NOTICE OF PRIVACY PRACTICES AVAILABILITY

The terms described in this notice will be posted in the waiting area. A hard copy will be provided at yourrequest.

 

I have read and agree to the HIPPA compliancy policy.

Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations.

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.

I understand that this information serves as a basis for planning my care and treatment; a means of communication among the many health professionals who contribute to my care; a source of information for applying my diagnosis and information to my bill; a means by which a third-party payer can verify that services billed were actually provided; and as a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided.

I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon.

If you would like to request restrictions to the use or disclosure of your health information, please inform us of your resuest on your first visit.