Welcome to Our Office
What brings you to the office? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
How has this affected your family or job? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have there been any legal problems? _______ Yes _______ No Please explain: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are you experiencing any of the following?
□ Weight gain- how much ________ □ Weight loss- how much ________ □ Changes in appetite □ Sleep disturbances □ Other __________________________________________________________
Do you consider your general health to be ___ excellent ___ good ___ fair ___ poor
Please list Current medications: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Any allergies to medication? ________ If so, what? _________________________
Past Psychiatric Treatment:
______ Inpatient ______ Outpatient ______ None
Physician/ Therapist___________________________________________________
Have you ever taken anti-depressant/ anti-anxiety medication? ____ yes ____no
Was psychological testing done? _____yes _____no, if so, when______________
Pertinent Family History (medical/psychiatric): _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Alcohol/ drug use (past or present) Amount / Frequency Periods of past use _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you feel that your drug/alcohol use is causing problems for you or your family? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Patients Social History: With whom do you live?___________________________
Relationship with significant others? ____ good ____ bad Please Explain: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
To whom do you turn for support, and how do they help you? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you have a spiritual orientation or belief system? _____ yes _____ no
Please check the types of treatment you are interested in receiving: □ Individual □ Couples Therapy □ Medication Management □ Group Therapy □ Sex Therapy □ Psychological Testing |
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Financial Policy
This is an agreement between Bonnie R. Saks, MD, as creditor, and the Patient/Debtor
named on this form.
In this agreement the words "you," "your," and "yours" mean the Patient/Debtor.
The word "account" means the account that has been established in your name to which charges are made and
payments credited. The words "we," "us," and "our" refer to Bonnie R. Saks,
MD and Associates LLC. By executing this agreement, you are agreeing to pay
for all services that are received.
Monthly Statement: If you have a balance on your account, we will send you a monthly statement.
It will show separately the previous balance, any new charges to the account, and any payments or credits applied to
your account during the month. Unless other arrangements are approved by us in writing, the balance on your statement is due
and payable when the statement is issued, and is past due if not paid by the end of 30 days.
Insurance: Insurance is a contract between you and your insurance
company. We are NOT a party to this contract, in most cases. We will bill your primary
insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it
is the insurance company that makes the final determination of your eligibility. You agree to pay any portion
of the charges not covered by insurance. If your insurance company requires a referral and/or preauthorization,
you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result
in a lower payment from the insurance company.
Billing Information: You understand that it is your responsibility to notify the office of any changes in address,
phone number or insurance coverage, both primary and secondary.
Past due accounts: If your account becomes past due, we will take necessary steps to collect this
debt. If we have to refer your account to a collection agency, you agree to pay all of the collection costs which are incurred.
If we have to refer collection of the balance to a lawyer, you agree to pay all lawyers’ fees which we incur
plus all court costs.
Waiver of confidentiality: You understand if this account is submitted to an attorney or collection agency, if we have
to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment
at our office may become a matter of public record.
Returned checks: There is a fee (currently $37) for any checks returned by
the bank. This amount is subject to change without prior notification.
Missed appointment fee: Patients who do not show up on time for an appointment, or cancel with less than 48 hours notice will be charged a
$40 administrative fee. Patients with three missed appointments will be asked to transfer their records
to another doctor.
Transferring of Records: You will
need to request in writing, and pay a reasonable copying fee (currently $1 per page) if you want to have copies of
your records sent to another doctor or organization. This fee will be waived if records are being sent
to your primary care physician (PCP). You authorize us to include all relevant information, including your payment history.
If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to
receive all relevant information, including your payment history.
Co-signature: If this or another Financial Policy is signed by another person, that co-signature
remains in effect until canceled in writing. If written cancellation is received, it becomes effective
with any subsequent charges.
Effective Date:
Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement
will be in full force and effect.
Patient
should be aware that any medications prescribed have potential risk!
Patient’s name:______________________________________________________________________________
Responsible party
(If not the patient):____________________________________________________________________________
Signature: _______________________________________________
Date: ___________________________
Payment options if you have no insurance coverage:
A. You choose to pay by cash, check, or credit card on the day that treatment is rendered.
No checks for first visit.
Payment options: if you have insurance:
A. In network, you choose to pay your co-payment, your deductible and any out-of-pocket
portions at the time services are rendered by cash, check, or credit card Because this is an insurance
requirement, we cannot bill you for these. Check payments are not allowed for initial appointments.
B.
Out of network, you choose to pay the
total cost of your treatment by cash, check, or credit card. Your insurance carrier will send their payment directly to you.
This is an agreement between Bonnie R. Saks, MD, as creditor, and the Patient/Debtor named on this form.
In this agreement the words "you," "your," and "yours" mean the Patient/Debtor. The word "account" means the account that has been established in your name to which charges are made and payments credited. The words "we," "us," and "our" refer to Bonnie R. Saks, MD and Associates LLC. By executing this agreement, you are agreeing to pay for all services that are received.
Monthly Statement: If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, and any payments or credits applied to your account during the month. Unless other arrangements are approved by us in writing, the balance on your statement is due and payable when the statement is issued, and is past due if not paid by the end of 30 days.
Insurance: Insurance is a contract between you and your insurance company. We are NOT a party to this contract, in most cases. We will bill your primary insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower payment from the insurance company.
Billing Information: You understand that it is your responsibility to notify the office of any changes in address, phone number or insurance coverage, both primary and secondary.
Past due accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all of the collection costs which are incurred. If we have to refer collection of the balance to a lawyer, you agree to pay all lawyers’ fees which we incur plus all court costs.
Waiver of confidentiality: You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.
Returned checks: There is a fee (currently $37) for any checks returned by the bank. This amount is subject to change without prior notification.
Missed appointment fee: Patients who do not show up on time for an appointment, or cancel with less than 48 hours notice will be charged a $40 administrative fee. Patients with three missed appointments will be asked to transfer their records to another doctor.
Transferring of Records: You will need to request in writing, and pay a reasonable copying fee (currently $1 per page) if you want to have copies of your records sent to another doctor or organization. This fee will be waived if records are being sent to your primary care physician (PCP). You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history.
Co-signature: If this or another Financial Policy is signed by another person, that co-signature remains in effect until canceled in writing. If written cancellation is received, it becomes effective with any subsequent charges.
Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.
Patient should be aware that any medications prescribed have potential risk!
Patient’s name:______________________________________________________________________________
Responsible party
(If not the patient):____________________________________________________________________________
Signature: _______________________________________________ Date: ___________________________
Payment options if you have no insurance coverage:
A. You choose to pay by cash, check, or credit card on the day that treatment is rendered. No checks for first visit.
Payment options: if you have insurance:
A. In network, you choose to pay your co-payment, your deductible and any out-of-pocket portions at the time services are rendered by cash, check, or credit card Because this is an insurance requirement, we cannot bill you for these. Check payments are not allowed for initial appointments.
B. Out of network, you choose to pay the total cost of your treatment by cash, check, or credit card. Your insurance carrier will send their payment directly to you.
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This is an agreement between Bonnie R. Saks, MD, as creditor, and the Patient/Debtor named on this form. In this agreement the words "you," "your," and "yours" mean the Patient/Debtor. The word "account" means the account that has been established in your name to which charges are made and payments credited. The words "we," "us," and "our" refer to Bonnie R. Saks, MD and Associates LLC. By executing this agreement, you are agreeing to pay for all services that are received. Monthly Statement: If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, and any payments or credits applied to your account during the month. Unless other arrangements are approved by us in writing, the balance on your statement is due and payable when the statement is issued, and is past due if not paid by the end of 30 days.
Insurance: Insurance is a contract between you and your insurance company. We are NOT a party to this contract, in most cases. We will bill your primary insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower payment from the insurance company.
Billing Information: You understand that it is your responsibility to notify the office of any changes in address, phone number or insurance coverage, both primary and secondary.
Past due accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all of the collection costs which are incurred. If we have to refer collection of the balance to a lawyer, you agree to pay all lawyers’ fees which we incur plus all court costs.
Waiver of confidentiality: You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.
Returned checks: There is a fee (currently $37) for any checks returned by the bank. This amount is subject to change without prior notification.
Missed appointment fee: Patients who do not show up on time for an appointment, or cancel with less than 48 hours notice will be charged a $40 administrative fee. Patients with three missed appointments will be asked to transfer their records to another doctor.
Transferring of Records: You will need to request in writing, and pay a reasonable copying fee (currently $1 per page) if you want to have copies of your records sent to another doctor or organization. This fee will be waived if records are being sent to your primary care physician (PCP). You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history.
Co-signature: If this or another Financial Policy is signed by another person, that co-signature remains in effect until canceled in writing. If written cancellation is received, it becomes effective with any subsequent charges.
Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.
Patient should be aware that any medications prescribed have potential risk!
Patient’s name:______________________________________________________________________________
Responsible party (If not the patient):____________________________________________________________________________
Signature: _______________________________________________ Date: ___________________________
Payment options if you have no insurance coverage:
A. You choose to pay by cash, check, or credit card on the day that treatment is rendered. No checks for first visit.
Payment options: if you have insurance:
A. In network, you choose to pay your co-payment, your deductible and any out-of-pocket portions at the time services are rendered by cash, check, or credit card Because this is an insurance requirement, we cannot bill you for these. Check payments are not allowed for initial appointments.
B. Out of network, you choose to pay the total cost of your treatment by cash, check, or credit card. Your insurance carrier will send their payment directly to you. |