Forms

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New Patient Registration
Insurance Name
Insurance Id
First NamePlease write your first name
Middleyour full name
Last NamePlease write your Last name
Date of BirthInsert your date of birth
Social Security NumberPlease write your SSN
Sexpick one!
Address
Apt
City
State
ZIP
Phone(H)
Phone (C)
Emergency Contact
NamePersons Full Name
Relationship
PhoneEmergency Contact's Phone Number
NamePersons Full Name
Relationship
PhoneEmergency Contact's Phone Number
Please Sign

I am fully responsible for all payment for services rendered by the Doctors and or staff of Reflections of Health, Inc. not paid by my Medical Insurance Company.

SignatureName and Last Name
DateSelect Today's Date

I also give permission for this office to use a laboratory for process any test the Doctors an / or staff members of Reflections of Health, Inc feel is necessary.

SignatureName and Last Name
DateSelect Today's Date

TO RECEIVING AGENCY: PROHIBITION OF REDISCLOSURE:

THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED. ANY FURTHER REDISCLOSURE IS STRICTLY PROHIBITED UNLESS THE PATIENT PROVIDES SPECIFIC WRITTEN CONSENT FOR THE SUBSEQUENT DISCLOSURE OF THE THIS INFORMATION.

Past Psychiatric History
Social History
Please list all the psychiatric history you can remember
0 /
If you selected any of the boxes, tell us a bit more about it.How much often do you consume alcohol? How many packs of cigarrettes per day? What kind of Illicit drugs?
0 /
Year QuitIf you selected any of the options above, tell us what year you quit.
Family History
MotherFatherOtherUnknown
Alcohol Use
Tobacco Use
Illicit Drugs
Mental Illness
Medical AllergiesPlease list all that describes
Any Hospitalization in the past 90 days Psych Related?If so, please describe.
Current MedicationsPlease list all

TO RECEIVING AGENCY: PROHIBITION OF REDISCLOSURE:

THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED. ANY FURTHER REDISCLOSURE IS STRICTLY PROHIBITED UNLESS THE PATIENT PROVIDES SPECIFIC WRITTEN CONSENT FOR THE SUBSEQUENT DISCLOSURE OF THE THIS INFORMATION.

Patient Authorization of Release Form
I HEREBY GIVE MY PERSMISSION TO:To Release a copy of Medical/Hospital Records to Include and not Limited to:
  1. COMPLETE MEDICAL RECORD     
  2. DRUG AND ALCOHOL HISTORY
  3. PHYSICIAN ORDERS
  4. PSYCHIATRIC RECORDS
  5. RADIOLOGY REPORTS
  6. LABORATORY

TO: REFLECTIONS OF MENTAL HEALTH, INC

18425 NW 2nd Ave, Suite 404B
Miami Gardens, FL 33169
Phone: (305) 549-8100

Fax: (786) 565-3015


This authorization is subject  to revocation at any time, by written request, except to the extent that action has been taken in reliance thereon, and in any authorization expires without express revocation one (1) year the data that appears below. 


I HEREBY RELEASE THE FACILITY FROM ANY LIABILITY WHICH MAY ARISE AS A RESULT OF THE USE OF THE INFORMATION CONTAINED IN THE RECORDS RELEASED: 

Nameyour full name
DOByour date of birth
SSNEnter your Social Security Number
Signature Of Patientyour full name
DATE
Signature of Witnessyour full name
DATE

TO RECEIVING AGENCY: PROHIBITION OF REDISCLOSURE:

THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED. ANY FURTHER REDISCLOSURE IS STRICTLY PROHIBITED UNLESS THE PATIENT PROVIDES SPECIFIC WRITTEN CONSENT FOR THE SUBSEQUENT DISCLOSURE OF THE THIS INFORMATION.

PATIENT CONSENT FORM

SECTION A:

Patient Giving Consent:

Last Name
First
Middle
DOB

SECTION B:

TO THE PATIENT (PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY)


Purpose of Consent:

By signing this form, you will consent to our use and disclosure of you Protected Health Information to carry out treatment and payment activities.


Notice of Privacy Practice:


You have the right to read our Notice of Privacy Practice before your decide whether to sign this Consent. Our notice provides a description of our treatment payment activities and healthcare operations, of the uses and disclosures we make of your protected health information, and of other important matters about  your protected health information, read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices and described in our Notice of Privacy Practices. If We change our privacy practices, we will post in our office as well as issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of our protected health information that we maintain. Your may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contracting. 


CONTACT PERSON: 

Reflections of Mental Health, Inc

ADDRESS: 

18425 NW 2nd Ave Suite 404B

Miami Gardens, FL 33169

Phone (305) 549-8100

Fax: (786) 565-3015


Right to Revoke:


You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person/ Department listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or continue treating your revoke this Consent:


I (type your full name)Have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this form, I am giving my consent to sude and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations.
SignatureYour Full Name
DateType today's date

TO RECEIVING AGENCY: PROHIBITION OF REDISCLOSURE:

THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED. ANY FURTHER REDISCLOSURE IS STRICTLY PROHIBITED UNLESS THE PATIENT PROVIDES SPECIFIC WRITTEN CONSENT FOR THE SUBSEQUENT DISCLOSURE OF THE THIS INFORMATION.

PATIENT RIGHTS

- Right to refuse and/or terminate treatment at any time.

- Right to access and obtain a copy of your health information.

- Right to an accounting of disclosures made on your health information.

- Right to request an amendment to your health information information. 

- Right to request confidential communications,. Request that we communicate with you about your health information at alternative locations. 

- Right to restrict certain disclosures of your health information. 

- Right to complain if you feel that we have used or disclosed your health information inappropriately. 

- The right to know the ways in which Reflections of Mental Health, Inc uses and discloses your health information for tretment, payment, and health care operations. 

- The right to authorize and revoke release of medical or health information. 

I hereby certify and understand the above patient rights.

Name of PatientYour Full Name
Birth Date:
Social Security Number:
Signature of PatientYour Full Name
Today's Date
Witness SignatureYour Full Name
Today's Date

TO RECEIVING AGENCY: PROHIBITION OF REDISCLOSURE:

THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED. ANY FURTHER REDISCLOSURE IS STRICTLY PROHIBITED UNLESS THE PATIENT PROVIDES SPECIFIC WRITTEN CONSENT FOR THE SUBSEQUENT DISCLOSURE OF THE THIS INFORMATION.

OFFICE POLICIES

Please read, initial and sign the following information concerning the policies of this office. You will be given a copy for your records. 

A. INSURANCE PAYMENT ORDERyour initials
IWrite your name

Hereby authorize Reflections of Mental Health Inc. to sude my information when conducting business with my insurance company. I understand that my health information will be used, as needed, to obtain payment for my health careservices from my insurance providers. This may include certain activities the Reflections of Mental Health, Inc. staff may need to undertake e before my health care insurer approves or pays for health care services recommended for me; such as determining eligibility or coverage for benefits, reviewing services provided to me for medical necessity, and undertaking utilization review activities.

B. PAYMENT POLICY:your initials

You are responsible for all co-payments and/or fees at the time of service, otherwise billing fees will be incurred. If another party is responsible for your payments, please let us know prior to your visit so that we may make the necessary arrangements. 


A fee of $35.00 will be charged for any return checks, along with a processing fee. 

C. CANCELLATION POLICY:your initials

Appointments are scheduled according to each patient's needs and the availability of the physician. The time of your appointment is reserved for you. All cancellations and/or rescheduling of appointments MUST be done at least 24 hours in advance. Failure to call in advance to cancel their appointment will considered a NO SHOW and will incur a $25.00 cancellation/no show fee. Confirmation calls are done as a courtesy to patients; however, there are times we cannot make them. Please do not rely on our call. 

D. MAINTAINING PATIENT STATUS:your initials

In regards to mental health, it is very important that you be seen on a regular basis. At the end of each appointment, you will be given a follow-up appointment. It is recommended that you make the follow-up appointment before you leave our office in order to shceldule the most convenient time for your. If you fail to keep and/or maintain follow-up appointments for a period of six months (180 days) or greater, we will conclude that you have terminated the patient-physician relationship and would no longer be an active patient. 

E. TERMINATION OF CARE:your initials

Dr. Samuel reserves the right to terminate the patient-physician relationship if the patient is repeatedly noncompliant with treatment recommendations despite repeated redirection and use of available resources and/or inability to mainatain a terapeutic relationship due to repeated conflicts or inability to mainatin professional boundaries. The termination of care will be provided in writing via certified mail along with a list of treament providers. 

F. MEDICATION REFILLS:your initials

We handle all refills during your regular scheduled appointments. If a medication refill becomes necessary, please provide us with your pharmacy phone number, medication name and how you are currently taking your medication. NO medications refills via telephone or fax will provided if you have not been seen by the provider greater than 90 days. Refills for medications may be subject to a $25 fee. 

G. CHANGES TO TREATMENT PLAN/MEDICATION REGIMENyour initials

No changes to medication or dosage will be done via telephone. All changes to treatment plan/medication regimen will be done via scheduled face to face visit either in office or secure video tele-psychiatry. 

H. CONFIDENTIALITYyour initials

Your patient records are stictly confidential. For this reason, no information concerning you as a patient is released without your written consent. Disclosure of information to anyone such as another doctor, an attorney and/or a family member must be requested by written authorization by the patient. In an emergency situation when you, the patient, are at imminent risk of death or serious medical consequence:  minimal, critically relevant information to assist is preventing dire medical sconsequences that may result if that relevant information is not released. In the case of a minor, their legal guardian must sign the authorization. The physician is legally bound to break doctor-patient confidentiality in cases of threat of harm to self or others, medical emergency, and in reports of a child or geriatric abuse. 

I. FMLA Forms/Medical Resports/Correspondence/Disability Formsyour initials

While medical reports to insurance companies and employers are necessary for you to access benefits, they are not medically necessary for your treatment. Therefore, we charge for these additional tasks. Please allow 5 to 7 days for completion of your requests after we have all the appropriate releases and/or information to complete the forms. Paperwork is billed at $25 or more based on the complexity. No exceptions!

J. EMERGENCY SITUATIONSyour initials

In the case of a pshychiatric emergency call 911 or go to your local emergency room. 

I have read and understand the information abovePatient or Guardians's full name
WitnessWitness' full Name
DATEToday's date

TO RECEIVING AGENCY: PROHIBITION OF REDISCLOSURE:

THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED. ANY FURTHER REDISCLOSURE IS STRICTLY PROHIBITED UNLESS THE PATIENT PROVIDES SPECIFIC WRITTEN CONSENT FOR THE SUBSEQUENT DISCLOSURE OF THE THIS INFORMATION.

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
NAME:Full Name
DATEToday's date

Over the last 2 weeks, how often have you been bothered by any of the following problems? 

Please choose what describes best.
(0) Not al all(1) Several Days(2) More than Half The Days(3) Nearly Every Day
1- Little interest or pleasure in doing things
2- Feeling down, depressed, or hopeless
3- Trouble falling or staying asleep or sleeping too much
4- Feeling tired or having little energy
5- Poor appetite or overating
6- Feeling bad about yourself, or that you are a failure or have let yourself or your family down
7- Trouble concentrating on things, such as reading the newspaper or watching television
8- Thoughts that you would be better off dead, or of hurting yourself.
TOTALAdd the total for all the answers combined, based on what column you chose (0-3), and type it here.
If you checked off any problems, how difficult have these problems made it for your to do your work, take care of things at home, or get along with other people?
(0) Not difficult at all(1) Somewhat difficult(2) Very Difficult (3) Extremely Difficult
Choose one:
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