Child/Adolescent New Patient Form

Responsible Party (If other than the patient):

Scheduling Appointments

Please prepare to confirm your appointment with Visa or Master Card; we will charge $1 on the
card and keep it on file. Self-pay patients need to make the full payment to confirm appointment.
There are charges to fill up paper work please see the payment agreement form. Our practice will
always accommodate your scheduled time how ever due to the complexcity and emergency
condition of the patient ahead of you, there may a delays or a long delays which circumstance is
out of our hand. We appreciate your patience and cooperation during these times. Our staff will
do everything possible to provide the best treatment you and your family needs. Please let us know your urgency upon arrival for your visit. We request new patient to 60 minutes prior to the
appointment time and 15 minutes prior to your follow up visit. The appointment is final. We may
try to have courtesy reminder call for your schedule appointment. Patient is responsible to keep
the appointment to avoid no show fees.

What to Bring:

• You MUST bring all your medication with the container with patient name and prescribing provider's information.
• You MUST complete all forms on our website prior to the time of your appointment. Also please sign your Authorization for Release of Medical Record’s Information to Previous Practitioner (Primary Care Doctor / Psychiatrist)
• You MUST email Driver's Liscense (parent's DL if patient is under 18) and Insurance Card to info@psychiatricclinic.net

* Authorization for Care & Treatment, HIPAA Regulation & Consent, Payments Agreement, Patient
Questionnaire, Release of Medical Records Form.

We must have your current valid Photo ID, if there is a Child or Adolescent, we will need Child’s school
Photo ID, prior Medical Records, prescribed medication with container and your copayment prior to the
visitation with the provider. If you are adoptive parents, Care providers, Step Parents or Custodial
Parents we will need official court order, adoption paper, official court orders with the authorization for
the medication and treatment of the child and Adolescent patients.

For a New Child or Adolescent patient we must have an initial visit with the parents only and then we will have an initial visit with the Child or Adolescent patient with the parents. The parents must bring the patient only no sibling at the time of the visit.

For the Adult treatment of ADHD or ADD the provider’s requires neuropsychological testing and urine drug screens before start of stimulant medications.

***Please get the neuropsychological testing ONLY done by a PHD level psychologist.***

For the prior authorization of medication there may be a fees and will take 7 days to get approval by the prescription insurance company. Our office prescribe medication for 30 days only and requires a follow up visit to receive prescription.

***Our office does not participate in FMLA, Emotional Support Animal (ESA) letter, or disability testing.***

Office Policy

• If the patient misplaces (including lost or stolen) a control substance prescription within the time period before the next appointment, the prescribing physician will not write another prescription. It is the patient’s or guardian's sole responsibility to keep the prescription in a safe protected place. The call in prescription fees will be charged only if the patient requires a refill
• For the safety of our patients and staff, please do not bring any food or drink, any concealed weapons, or any sharp items. Any photography and/or video recording is prohibited.
• Insurance DOES NOT cover over the phone conversations. If you need to have your appointment over the phone, conversations and therapies are charged at a $440.00 self-pay rate.
• Any patient with litigation must pay for all the litigation fees arising between the parties. They must indemnify and hold harmless to Bay Hill Psychiatric Associates, its staff, Dr. Syeda Sultana and all the providers for litigation, court ordered subpoenas, and compliance of court orders.

We thank you for your patience and appointment request we will get back to as soon as possible to confirm you appointment.

Please type and print your name below as an acknowledgement of all the terms and condition regarding your appointment with our office:

AUTHORIZATION FOR CARE AND TREATMENT

Therapist: Syeda N. Sultana, M.D.

1. I recognize that a condition exists requiring psychiatric/psychological care and do herby voluntarily consent to such care, medical care and treatment and diagnostic procedures by Bay Hill Psychiatric Associates, LLC (medical professional staffs, employees & agents) or as deemed necessary.

2. I hereby authorize the physician assigned, as provided by law, to furnish psychiatric/psychological care or therapy, including administration of psychiatric medication.

3. I am aware that the practice of medicine, including psychiatry and psychology, are not exact sciences, and I acknowledge that no guarantees have been made to me as to the result of diagnostic procedures, medical procedures, treatments, examinations or care undertaken.

4. The contents of this form have been fully explained to me and I have been given the opportunity to ask questions. Any questions which I have asked have been answered to my satisfaction. I certify that I understand the contents of this form and that all blanks have been crossed out or
filled in.

I UNDERSTAND THAT I AM ENTITLED TO AN EXACT COPY OF THIS AGREEMENT

CONSENT FOR TELEMENTAL HEALTH SERVICES

1. In light of COVID-19 precautions, my health care provider and I have mutually decided to engage in a telehealth consultation. Telemental health is a temporary service that is being offered due to extreme circumstances as a precautionary measure. When the crisis passes, therapy sessions will return to being in-person.

2. Video conferencing technology is not the same as a direct Patient/ Provider visit due to the fact the Psychiatrist and patients are not in the same room. Visual or auditory cues that are more apparent in-person may be missed in a video chat.

3. Confidentiality still applies for telemental health services, and nobody will record the session. However, you must make sure you are in a secure room where no one can hear your conversation and you can have minimal interruptions. Also, please use a secure internet connection rather than public/free Wi-Fi for your privacy.

4. As a Provider, I will also take every precaution to ensure technologically secure, HIPAA compliant, and environmentally private psychotherapy sessions. I cannot control the technology freezing, crashing, or bad connections, but I will work with you every way we can to ensure the best possible interactions.

5. A smartphone, webcam & audio enable equipment, laptop, the tablet will need to be enabled during the session. Headphones or earbuds may improve sound quality and increase your privacy. Some clients may choose to sit in their car for the session for the utmost privacy.

6. I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of a child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding, physical health danger).

7. I understand that Telemental health is not a substitute for crisis/emergency services, please call the crisis hotline 800-273-8255, For a life-threatening emergency, dial 911, or go directly to your local Mental Health hospital emergency room.

8. I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required. I understand that my Telemental health providers may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

9. I understand that a telehealth consultation has potential benefits including easier access to care, less potential exposure to COVID-19, and the convenience of meeting from a location in Florida of my choosing.

10. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. This will not jeopardize my access to future care, services, and benefits. IN CASE OF TECHNOLOGY FAILURE If service is disrupted due to a tech failure, please phone us at 407 903 9696. We may choose to reschedule if there are problems with connectivity. STRUCTURE and COST OF THERAPY SESSIONS: Telemental health sessions are the same fees as face to face sessions. ($440 per session). It is the understanding of the provider that Telemental health sessions during the current COVID-19 outbreak may be covered the same as in-person a session with your insurance company. Prior to any session, please verify insurance status and coverage. Please contact your insurance to verify coverage via Telemental health before engaging in it so you are clear about what the cost will be to you. Payment is the responsibility of the Patient or guardian regardless of insurance reimbursement and is due at the time of service. RELEASE OF LIABILITY: I unconditionally release and discharge Syeda N. Sultana, M.D., Bay Hill Psychiatric Asssociates, LLC DBA Psychiatric Clinic.net, Providers, trainees, staffs, and employees, from any liability in connection with my participation in the remote consultations. By signing this form, I certify: • That I have read or had this form read and/or had this form explained to me. • That I fully understand its contents including the risks and benefits of the procedure(s). • That I have had a direct conversation with my staff of the provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits, and any practical alternatives have been discussed with me in a language in which I understand

HIPPA REGULATION AND CONSENT

Required by the Health Insurance Portability and Accountability Act --- 45 CFR Parts 160 and 164

Visit the link below to see HIPPA Regulations:

https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/administrative/combined/hipaa-simplification-201303.pdf

• I have previously received the HIPAA regulation and do not wish to receive a copy today.
• I have received a copy of the HIPAA regulation today

I hereby request the following regarding the use of my Personal Health Information:

You may leave the following message on answering machines:
1. Referral information
2. Prescription refill information
3. Test results
4. Appointment reminder
5. All of the above

You may contact me regarding my treatment and care at the following numbers:

You may talk to the following people in my family about care, appointment, test results, etc:

PAYMENT AGREEMENT

I clearly understand and agree that all services rendered to me personally and/or to a minor or other person under my guardianship are charged to my credit card directly to me and I am financially responsible for payment for the office visit. There are no refunds or charge backs for the services, (No show fees)missed appointments
and other charges below:

ASSIGNMENT AND RELEASE

I, the undersigned have insurance coverage with:

All medical benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by Medicare/the Insurance Company. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all my insurance/financial institution submissions whether manual or electronic:

I have read, understand and accept the payment instructions given to me at this time of my first visit.

THIS SIGNED FORM WILL SERVE AS MY SIGNATURE ON FILE, UNLESS OTHERWISE SPECIFIED. I GIVE PERMISSION TO DR. SYEDA N. SULTANA TO TREAT ME/MY CHILD AS HER PATIENT IN HER OFFICE/VIRTUALLY UNLESS OTHERWISE SPECIFIED IN WRITING.

I am responsible as a self-pay patient an initial visit of $440.00 & follow up visits at $270.00 paid in advance at the time of Appointments. All Market place Insured patient may have to pay self pay rate until we receive payment from insurance company. After reviewing the EOB the refund will be provided to the Credit Card it was charged originally. If my insurance company refuses to confirm payment or my insurance expired at the time of my visit a selfpay visit rate will be charged to the credit card on file for the services

CANCELLATION AND OTHER CHARGE POLICY

I understand that I will be charged for appointments not kept and which were not canceled 48 hours (2 business days, excluding Tuesday) in advance of the appointment time. Since insurance companies cannot be billed, I will pay for missed appointments, and I am personally responsible and authorizing no
show fess to be charges to my credit card on file for such payment(s).

• $200.00 charge for new patient missed appointments. $440 for the self pay patient.
• $100.00 charge for follow-up missed appointments. $270 for the self pay patient.
• $100.00 charge for refill without office visit/virtual appointment, call in or lost prescription, for returned check.
• $440.00 charge for short term, long term, Medicare, Social Security, disability, any insurance company, CPA, court, attorney & FMLA documents.
• $440.00 hourly charge (minimum) for any personal letters, medical record review/dispersement & any forms filled by the doctor.

I HEREBY AUTHORIZE SYEDA N. SULTANA, M.D. / BAY HILL PSYCHIATRIC ASSOCIATES, LLC TO RELEASE ALL INFORMATION NECESSARY TO SECURE PAYMENT AND ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND ACCEPTED THE FORGOING STATEMENTS.

Patient Questionnaire

Consent for Treatment and Limits of Liability

Limits of Services and Assumption of Risks:

Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of
distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these
improvements and any “cures” cannot be guaranteed for any condition due to the many variables that
affect these therapy sessions. Experiencing uncomfortable feelings, discussing unpleasant situations
and/or aspects of your life are considered risks of therapy sessions.

Limits of Confidentiality:

What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written may be shared with another party without your written consent or the written consent of your legal guardian.

The following is a list of exceptions:

>> Duty to Warn and Protect <<

If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan to threat or harm another person, the therapist is required to warn the possible victim and notify legal authorities.

>> Abuse of Children and Vulnerable Adults <<

If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (i.e. the elderly, disabled/incompetent), the therapist must report this information to the appropriate state agency and/or legal authorities.

>> Prenatal Exposure to Controlled Substances <<

Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child.

>> Minors/Guardianship <<

Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.

>> Insurance Providers <<

Insurance companies and other third-party payers are given information that they request regarding services to the clients.
The type of information that may be requested includes: types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, summaries, etc.

By signing below, I agree to the above assumption of risk and limits of confidentiality and understand their meanings and ramifications.

RELEASE OF INFORMATION

Required by the Health Insurance Portability and Accountability Act --- 45 CFR Parts 160 and 164

I hereby Authorize:

Bay Hill Psychiatric Associates, LLC
Syeda N. Sultana, M.D.
Board Certified Adult & Child/Adolescent Psychiatrist
Tel: 407-903-9696
Fax: 407-903-9698
psychiatricclinic.net

To:

The information requested or authorized for release or exchange pertains to:
a. Mental Health
b. Education
c. HIV/Transmitted disease
d. Drug or alcohol abuse

This authorization is valid for 90 days from the date below. I may cancel this authorization by signing, dating and writing “CANCEL” on this original form or by sending a written, signed and dated request to the doctor above indicating my desire to cancel. I understand that once my information has been released, the recipient might re-disclose it; my doctor has no control over it and privacy laws may no longer protect it. The purpose of this authorization is to improve the quality of my health evaluation and/or treatment.

Children's Depression Inventory (CDI)

Kids sometimes have different feelings and ideas.

This form lists the feelings and ideas in groups. From each group, PICK OUT THE SENTENCES THAT BEST DESCRIBE YOUR FEELINGS AND IDEAS IN THE PAST TWO WEEKS.

After you pick a sentence from the first group, go on to the next group.There is no right answer or wrong answer. Just pick the sentence that best describes the way you have been recently.

Fill in the circle → ○●◌ next to the sentence that you pick for your answer.