New Patient Forms

New Patient Intake Forms Patient Name:

Visit Information

Chief Complaint:

How did you hear about us?

Patient Information

First Name:

Last Name:

Nick Name

Date of Birth:

Gender:

Marital Status:

Primary Language:

Occupation:

Current Employer:

Employment Status:

Race:

Ethnicity:

Social Security Number:

Driving License Number:

Street Address:

Apt #:

City:

State:

Zip:

Mobile Number:

Home Phone Number:

Work Phone Number:

Email Address:

Primary Phone Number:

Secondary Phone Number:

Tertiary Phone Numbers:

Responsible Party Information

First Name:

Last Name:

Nick Name:

Date of Birth:

Gender:

Marital Status:

Relationship To Patient:

Primary Language:

Occupation:

Current Employers:

Employment Status:

Race:

Ethnicity:

Social Security Number:

Driving License Number:

Contact Information

Street Address:

Apt #:

City:

State:

Zip:

Mobile Number:

Home Phone Number:

Work Phone Number:

Email Address:

Primary Phone Number:

Secondary Phone Number:

Primary Insurance Information

Insurance Plan Information

Insurance Company Name:

Insurance ID:

Insurance Group:

Policyholder information

First Name:

Last Name:

SSN:

Date of Birth:

Relation to Patient:

Current Employers:

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Family members & Emergency contact

Types of Information about relationship

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Current and Referring Physicians

NOTE: If you have any be sure to add your current Psychiatrist, Therapist, Primary Care Physician, and Referring Physician.

Patient has no current physicians to report

Name

Type

Specialty

Pharmacy Location

Note: Be sure to add a pharmacy location that is most convenient for you to pick up your prescriptions

Pharmacy Name:

Phone:

Address:

City:

State:

Zip:

Medical History Comms-

Patient Name:

Visit Information

Chief Complaint:

How did you hear about us?

Interest in an FDA Approved treatment that can have you better in six weeks

This questionnaire is to screen by patents to determine if the patient might be a good candidate for TMS Therapy which is performed here in our office. This proven therapy is used at the Mayo Clinic, Johns Hopkins and Water Reed medical facilities.

Please Answer The Below Questions Accurately.

Have you tried TMS Therapy before?

Yes No

Are you interested in speaking with a patient advocate regarding your additional maintenance therapy?

Yes No

Estimate the number of antidepressants you have tried?

None 1-2 3-4 4 or more

Are you Interested in speaking with a Patient Advocate about a FDA approved, effective, and a non-medication treatment for recurrent depression available to you in this office?

Yes No

Interest in Dietary Supplementation for Mood, Focus and Sleep Support

Nutrient deficient food choices and inadequate vitamin supplementation can be problematic for brain health.

Advyndra® (pronounced ad-vin-druh) is a proprietary blend of important amino acids and B vitamins necessary for neurotransmitter production and functioning in the central nervous system-serotonin, dopamine, and norepinephrine-formulated by osteopathic physician and psychiatrist Dr. Germaine Hawkins, D.O. Advyndra® is not FDA approved for the treatment of any medical or psychiatric condition nor is it's use intended to diagnose or treat any Illness. Do not take this supplement without physician supervision.

Are you worried that your diet is not giving you enough to support your optimal mental functioning?

Yes No

Have you experienced any of the following in the last 6 months?

Yes No

Are you Interested In dietary ways to Increase your brain levels of dopamine, which helps with lifting your mood?

Yes No

Are you interested in dietary ways to Increase your brain levels of serotonin, which helps with anxiety and sleep?

Yes No

Are you interested in dietary ways to Increase your brain levels of norepinephrine, which helps with focus and attention span?

Yes No

Have you taken prescriptions drugs to help your mood, focus, or sleep but experienced undesirable side effects?

Yes No

Would you be interested in learning about Advyndra®, a psychiatrist formulated brain supplement that supports brain health?

Yes No

Psychiatric Health -

Your Current State Your Current State

Are you having thoughts of harming yourself?

Yes No

Are you having thoughts of harming other people?

Yes No

Current Stressors

None to report

Legal

School

Relationship

Financial

Work

Illness

Family

Other:

Have you ever received electro-convulsive (shock) therapy?

Yes No

Psychiatric Hospitalizations
Report any psychiatric hospitalization you have had in the past

Patient has no hospitalizations to report.

Reason

Year

Hospital Name

Comments

Social History - Substance Use

What type of alcoholic drinks do you consume?

How many alcoholic drinks do you consume in a week?

Did you quit drinking alcohol?

Yes No

Years since you quit drinking alcohol:

What type of tobacco products do you consume?

How frequently do you consume these tobacco products per day?

Did you quit smoking?

Yes No

Years since you quit smoking:

Do you use non-prescribed or recreational drugs?

Yes No

If yes, what type and at what dosage and frequency?

Social History - Reproductive (Questions for Women)

Are you pregnant?

Yes No

It pregnant, how many weeks are you into pregnancy? (0-40)

Are you taking folic acid and prenatal vitamins?

Yes No

Are you taking folic acid and Are you taking birth control pills, using any other form of contraception, or are your tubes tied?prenatal vitamins?

Yes No

Time since last menstrual period:

Medication and Supplement Dosages

Report at medications and supplements you are currently baking and medicate when you started taking them

Patient has no medications to report

Medications

Start Date (month/year)

Allergies

Report any medication or non-medication related allergies you have where applicable, add reactions

Patient has no allergies to report

Allergy

Reaction

Onset Date (month/year)

Comments

Past Medical History of diseases/conditions

Report past medical diseases or conditions that you've had where applicable, add dates and notes.

Patient has no medical diseases or conditions to report.

Type

Year (if applicable)

Notes (if any)

Family History

Report medical diseases or conditions in your family.

Patient has no family history of diseases to report

Relation to Patient

Disease

Depression Assessment (PHQ-9)

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

1. Little interest or pleasure in doing things

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

2. Feeling down, depressed, or hopeless

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

3. Trouble falling or staying asleep, or sleeping too much

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

4. Feeling tired or having little energy

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

5. Poor appetite or overeating

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

7. Trouble concentrating on things, such as reading the newspaper or watching television

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

8. Moving or speaking so slowly that other people could have noticed? Or the oppositebeing so fidgety or restless that you have been moving around a lot more than usual

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

9. Thoughts that you would be better off dead or of hurting yourself in some way

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficulty at all - 1 Somewhat difficult - 2 Very difficult - 3 Extremely difficult - 4

ATTRIBUTION: Dr. Kurt Kroenke MD. Robert L. Spitzer MD. Janet B. W. Williams DSW(2001)

Anxiety Assessment (GAD-7)

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

Feeling nervous, anxious or on edge

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

Not being able to stop or control worrying

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

Worrying too much about different things

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

Trouble relaxing

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

Being so restless that it is hard to sit still

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

Becoming easily annoyed or irritable

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

Feeling afraid as if something awful might happen

Not at all - 0 Several days - 1 More than half the days - 2 Nearly every day - 3

IIt you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficulty at all - 1 Somewhat difficult - 2 Very difficult - 3 Extremely difficult - 4

ATTRIBUTION Robert L. Spitzer, Kurt Kroenke, Janet B. W. Williams, Bernd Lowe (2006)
Permissions to Release Protected Data to Persons
Hawk Psychiatry 2800 E Broad Suite 400. Mansfield, Texas 76063
Enter details of related persons with whom we can exchange information with. For instance, a spouse or employee may be given scheduling permission so they can book appointments on the patient’s behalf.

Data permissions to give

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Permission for Staff to Leave Voice Messages

Enter contact details of patient or related persons to whom we can leave voice messages on the patient's behalf.

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Notice of Privacy Practices

Hawkins Psychiatry

THE FOLLOWING NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THE INFORMATION CAREFULLY.

Your Health Information Rights

Although your health record is the physical property of the practitioner who wrote it, the information belongs to you. You have the following rights

You can look at or get a copy of the health information that we have about you. An exception to this rule is that a psychotherapist may keep separate psychotherapy notes apart from the client or patient chart. Such notes are not part of the patient record and may not be released to anyone. There are some reasons why we will not let you see or get a copy of your health information, and if we deny your request, we will tell you why. You can appeal our decision in some situations. You can choose to get a summary of your health information instead of a copy You will be charged a fee for the summary or copy of your health information unless the records are being provided for the purpose of applying for government disability benefits.
You can ask us to correct information in your records if you think the information is wrong. We will not destroy or change our records, but we will add the correct information to your records and make a note in your records that you have provided the Information.
You can get a list of when we have given health information about you to other people in the last six years. The list will not include disclosures for treatment, payment, heath care operations, national security, law enforcement, or disclosures where you gave your permission. The list will not include disclosures made before April 14, 2003. There will be no charge for one list par year.
You can ask us to limit some of the ways we use or share your health information. We will consider your request, but the law does not require us to agree to it if we do agree, we put the agreement in writing and follow it, except in case of emergency. We cannot agree to limit the uses or sharing of information that are required by law.
You can ask us to contact you at a different place or in some other way. We will cure to your request as long as reasonable.
You can get a copy of this notice any time you ask for it.

Our Responsibilities:

The law requires us to protect the privacy of your health information. This means that we will not use or let other people see your health information without your permission except in the ways we tell you in the notice. We will not tell anyone you sought, are receiving, or have ever received services from anyone in this office, unless the law allows us to disclose that information.
We are required to give you this notice of our legal duties and privacy practices, and we must do what this notice says, We can change the contents of this notice and, if we do, we will have copes of the revised notice available to you at our office.
We are required to notify you if we are unable to agree to a requested restriction We are required to accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We will not use or disclose your health information without your authorization, except as described in this notice. We will not disclose information about you related to HIV/AIDS without your specific written permission

Disclosures for Treatment, Payment, and Health Operations
We will use your health information for treatment.

We may use health information about you to provide you with medical treatment or services. This includes providing care to you, consulting with another heath care provider about you, and referring you to another heath care provider. For example, we can use your health information to prescribe medication for you. Unless you ask us not to, we may also contact you to remind you of an appointment or to offer treatment alternatives or other health-related information that may interest you.

We will use your health information for payment.

We can use or disclose your health information to obtain payment for providing health care to you or to provide benefits to you under health plans such as Medicaid or Medicare. For example, we can use your health information to bill your insurance company for health care provided to you. Applicants for and recipients of financial assistance or payments under federal benefit programs are advised that any information provided by you may be subject to verification through matching programs.

We will use your health information for regular health operations

We can also use your health information for health care operations; for activities to improve health care, evaluating programs, and developing procedures: reviewing the competence qualifications, performance of health care professionals and others; conducting accreditation certification, licensing, or credentialing activities; providing medical review, legal services, or audit functions, and engaging in business planning and management or general administration.

UNLESS YOU ARE RECEIVING TREATMENT FOR ALCOHOL OR DRUG ABUSE, WE ARE PERMITTED TO USE OR DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR PERMISSION FOR THE FOLLOWING PURPOSES:

Business associates: There are some services provided in our organization through contracts with business associates. Examples include inpatient mental health services at certain hospitals, certain clinical laboratories, and private providers of medication management. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do and bill for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established rules to ensure the privacy of your health information.

Medical Examiners/Coroners: We may disclose heath information to Medical Examiners or Coroners consistent with applicable law to carry out their duties.

Workers compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

Correctional Institution: Should you be an inmate of a correctional institution; we may disclose to the institution or agents thereof heath Information necessary for your heath and the health and safety of other individuals.

Law enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid court order. Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public.

NOTICE FOR ALCOHOL IDRUG PATIENT RECORDS:

Confidentiality of Alcohol and Drug Abuse Patient Records The confidentiality of alcohol and drug abuse patient records maintained by this office is protected by Federal law and regulations. Generally, we may not disclose any information identifying a patient as an alcohol or drug abuser unless one of the following conditions is met:

The patient consents in writing.
The disclosure is allowed by a court order.
The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

Violation of the Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations.

Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime.

Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

FOR MORE INFORMATION OR TO REPORT A PROBLEM:

I have questions and would like additional information; you may contact our Privacy Officer at 817-496-7524. If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

U.S. Department of Health and Human Services: (800) 3684018 (toll free) 200 Independence Avenue. S.W.

Washington, DC. 20201 Effective Date April 14, 2003 Acknowledgement of Notice of Privacy Practices Hawkins Psychiatry I understand that I have certain nights to privacy, regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan, and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly
Obtain payment from third-party payers
Conduct normal health care operations such as quality assessments and physician certifications.

New Patient Intake Forms - Patient Name:

I have received the NOTICE OF PRIVACY PRACTICES from the office of Hawkins Psychiatry

I understand that the office has the right to change its NOTICE OF PRIVACY PRACTICES from time to time, and that may contact this office at any time to obtain a current copy of the NOTICE.

Financial Policies

Hawkins Psychiatry General Consent Initial Here* I consent to treatment by Dr. Hawkins & Associates through Hawkins Psychiatry, PC & Mind & Body Health Solutions, LLC.

ASSIGNMENT OF BENEFITS & AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize payment to this clinic of all benefits specified and otherwise payable to me for any services rendered by the clinic on or after this date and for such other charges as may be made by this clinic.

I hereby agree to pay the same and also agree that in the event that payment by a third party for any individual visit exceeds that which is necessary to cover charges incurred during that visit, any coverage may be applied to outstanding charges owed by the clinic for other services rendered to myself, my spouse, or legal dependents of myself or spouse at the time.

I certify that the information given by me in applying for payment under Tele XVll of the Social Security Act is correct. authorize any holder of medical or other information about me to release to the Social Security Administration, or its intermediaries, or any insurance earners all information needed for the completion of all medical claims. I understand that the information to be released may include information pertaining to mentalor psychiatric-related conditions and or drug or alcohol abuse. A copy of this authorization shall be as valid as the original.

Initial Here*

I hereby assign, transfer and set over to Provider, all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. authorize the release of any medical information needed to determine benefits, including medical, surgical, psychiatric and/or substance abuse (drug or alcohol) information. This authorization shat remain valid until written notice is given by me revoking said authorization. I understand that this order does not relieve me of my obligation to pay such bills if not paid by my Insurance Company, or of any balance due after payments by my Insurance Company.

Laboratory Testing

Initial Here*

In the event that I undergo any laboratory testing (i.e. urine tests, genetic testing), these may be billed through our on-site Physician-Owned Laboratory (POL).

Initial Here* I understand I have the right to use any outside laboratory of my choice at any time and I will be responsible for any copays or fees not covered by my insurance.

No-Show And Cancellation* Fees

Initial Here*

-For follow-up appointments and neurofeedback therapy, there is a non-refundable $50 fee if canceled within 24 business hours prior to appointment time.

-For TMS therapy sessions, there is a $100 fee if cancelled within 24 business hours prior to appointment time.

*We accept cancelation requests via phone or you may email our office at hawkinsstatt@gmail.com or you may reply via the appointment reminder text you receive if you have opted to receive them. As a reminder we close at noon on Fridays.

Text Message Appointment Reminder

As a courtesy, we offer optional text message appointment reminders that are sent from our HIPPA-compliant EMR (electronic medical records) system Practice Fusion. We will not send any messages without your approval. Please check with your mobile phone carrier for any associated fees for text messaging. We will not be financially responsible for any associated fees. This text messaging system will be used only for confirming and canceling appointments. Do not attempt to send or inquire about any other medical or health information when responding to these texts

Office Policies

Hawkins Psychiatry

POLICY REGARDING MEDICATION PRESCRIPTION REFILLS

As an established patient of Dr. Hawkins, it is office policy that all and any prescription refits are expected to be filled on the date of your follow-up appointment. You are expected to keep that appointment to maintain compliance. In the event you miss your appointment, it is imperative you make another appointment as soon as possible AFTER paying any fees incurred from late cancelation or no show. Either Dr. Hawkins or office staff will approve enough medications to get you to your next appointment. In the case of triplicate C-ll medications (e. Ritalin, Adderall). you will need to present to the office in person as a walk-in to speak with the physician and Dr. Hawkins will refill your prescription until your next scheduled appointment. In the case of triplicate medications C-ll and C-IV drugs (ie. Xanax, Valium, Klonopin, Ativan, Ambien, Lunesta), Dr. Hawkins will refill your prescription until your next scheduled appointment as long as you are not early on your refill (i.e. you were given a 30-day supply of Ritalin and it is only 21 days later).

In the event your medications were stolen, you will need to produce a POLICE REPORT as proof. you don't, it is at Dr. Hawkins' discretion whether or not to refill these drugs (C-ll or C-IV) as they can be abused. Lost prescriptions or medications will be handled on a case-bycase basis by appointment. In the event you choose to stop seeing Dr. Hawkins, you need to notify him in-person by scheduling a final appointment. Dr. Hawkins will refill your medications for at least a 30-day supply to give you time to find another provider.

It is YOUR responsibility to count and keep track of your medications to prevent running out outside of our normal business hours of Mon-Thurs. 9am to 5pm.

Initial here*

I have read the above and certify that will comply with the policy regarding medication prescription refills.

POLICY REGARDING AFTER HOURS E-MAIL CORRESPONDENCE AND RELATED DISCLOSURE OF PROTECTED HEALTH INFORMATION

Our office offers OPTIONAL e-mail correspondence to address after office hours questions and concerns regarding your mental health care including general inquiries about medications and treatment. The purpose of this option is NOT to substitute follow-up visits with the psychiatrist, but to serve as an alternate means of communication with your mental health care provider. In reply to your e-mail, you may sometimes be instead instructed to follow up in our office to address your concerns if the psychiatrist recommends so based on his professional medical opinion

The contents of the psychiatrist's corresponding e-mails may include your personal health information. In relevance to your e-mail question or concern, this could include (but may not be limited 10) your psychiatric diagnosis, prescribed medications, alcohol and drug history, and other medical diagnoses. Our office will NOT be held responsible for any individual who gains access to the contents of the corresponding e-mails regardless of the means by which it occurred.

If you are interested in our optional e-mail correspondence, initial below. If not, DO NOT INITIAL BELOW.

Initial here*

I agree to participate in the e-mail correspondence option. I certify that have read and understand the above information. decide to change my decision to participate in this option agree to do so by notifying our staff in writing

POLICY ON AFTER HOURS CALLS

Normal office hours are Mon-Thu, 9am to 5pm. Any emergency situations including, but not limited to, suicidal and/or homicidal, sell harm thoughts, hallucinations (seeing or hearing things not seen or heard by others) should be treated immediately and appropriately. The patient should call 911 and go to the nearest psychiatric emergency center as hated below. Dr. Hawking does not provide inpatient psychiatric care. It is important for continuity of care that you bring any discharge assessment, prescription changes, and other psychiatric care orders to your next appointment with Dr Hawkins.

New Patient Intake Forms - Patient Name:

MESA SPRINGS PSYCHIATRIC HOSPITAL
5560 Mesa Springs Dr
Fort Worth, TX 76123
(817) 292-4600
TEXAS HEALTH ARLINGTON BEHAVIORAL
800 W RANDOLL MILL
ARLINGTON Texas 76012
(682) 626 - 8719

Initial Here* I agree that the terms of the above policy will apply it request an after-hours callback by Dr. Hawkins

Hawkins Psychiatry
Disability Referral

Based on your psychiatric assessment, Dr. Hawkins or his mid-level providers (Nurse Practitioners) may determine that you quality for short term disability. You will be referred to a higher level of care-Partial Hospitalization Program (PHP) or Intensive Outpatient Program (OP) at one of the local facilities listed below. The referral will be based on your recent impairments, medical history, psychiatric history, subjective reports, and objective findings that suggest your current symptoms may cause work impairment. Our goal is to provide you with optimal psychiatric care as well as providing you with the tools to facilitate recovery to transition back to your work environment. YOUR COMPLIANCE WITH OUR RECOMMENDATIONS IS EXPECTED TO ENSURE QUALITY CARE. Noncompliance may result in referral to a different psychiatric clinic.

LOCAL FACILITIES With Partial Hospitalization And Intensive Outpatient Programs

Perimeter behavioral Hospital

7000 US Hwy 287 Arlington, TX 76001 817) 662-6341
HEB Springwood 2717 Tibbets Dr Bedford, TX 76022 (817) 355-7777

Huguley Behavioral Health Center

11801 South Fwy Burleson, TX 76026 (817) 568-3336

Hickory Trails Hospital

2000 N Old Hickory Trail DeSoto, TX 75115 (972) 298-7323

Disability/FMLA Fees"

Regarding short-term disability and/or FMLA (Family Medical Leave Act) paperwork, the fees charged are for the completion of the forms, including review of your chart and medical records from other physicians and/or therapists Payment of this fee and or completion of the form will NOT guarantee that your disability will be approved by your employer's disability company that handles your case. You will NOT be refunded any fees if your case is denied. Furthermore, our front office staff, mid-level providers, and Dr. Hawkins will NOT tolerate any offensive, derogatory. demeaning, or profane language (via face-to-face or telephone) in the event that you case is denied. Such behavior will result in your immediate termination from the practice.

*At Hawkins Psychiatry we differentiate between FMLA and Disability forms as follows:

If you are requesting time or days off to be used as needed in the event you feel incapable of performing your expected work duties (ie 2 days per week per episode) then the forms) would follow the fees associated with our FMLA fees
If you are suffering from significant distress rendering you incapable of performing your work duties even at a part time or reduced work schedule and your doctor recommends you not returning to work until an estimated return to work date and you are requesting paperwork to be completed, then the form(s) would follow the fees associated with Disability fees.
All fees are charged for the time that will be used completing the paperwork and are non-refundable. We do not guarantee your request will be approved.

Fee Amounts

Initial here*

-FMLA forms are $150 charge for initial completion and $150 per renewal, thereafter.

-Disability forms are $150charge for initial completion and $90 for requesting extensions of that same claim.

-you return to work from disability and initiate a new claim, you will be charged $125.

Policy Acceptance

Initial here*

I certify that have read, understand, and agree to comply with the above recommendations. understand that non-compliance may lead to my being referred to termination of care at Hawkins Psychiatry, PLLC

Urine Toxicology Screening Protocol

Hawkins Psychiatry

The Centers of Disease Control and Prevention has classified prescription drug abuse as an epidemic. While there has been marked decrease in use of some legal drugs are cocaine, dura from the National Survey on Drug Use and Health (NSDUH) show that nearly one third of people aged 12 and over who used drugs for the first time in 2009 began by using a prescription drug non-medically.

Some individuals who misuse prescriptions drugs, particularly teens, believe these substances are safer than it drugs because they are prescribed by a healthcare professional and dispensed by a pharmacist. Addressing the prescription drug abuse epidemic is not only a top priority for public health. It will also help build stronger communities and allow those with substance abuse disorders to lead healthier, more productive lives.

Here at Hawkins Psychiatry, PLLC. Dr. Hawkins treats a variety of disorders that require medications that, though very effective in treating a variety of disorders (including attention deficit disorder (ADD), panic disorder, social anxiety, Insomnia, opiate dependence, and various mood disorders), can be potentially abused it taken incorrectly. To decrease the likelihood of Intentional or unintentional misuse of prescription drugs, Dr. Hawkins orders urine toxicology screens for all new patients on initial visit and at random for follow up visits. Urine tests will either be in house (point-of-care) using dipstick only or sent out for confirmation. This information gathered from the screen is invaluable in safely prescribing medications to patients

Patients prescribed Suboxone (buprenorphine) or buprenorphine containing drugs, benzodiazepines (le Xanax, Valium, Klonopin, Ativan, etc.) or stimulants may be subject to more frequent screens, in the event that urine screens are positive for concomitant illicit substances or suggestive of noncompliance.

Not only are controlled medication levels tested via urine screens, but also prescribed antidepressants, bipolar disorder, and schizophrenic drugs are also tested to ensure compliance. In the event that prescribed medications are not confirmed by urine screen, the importance of medication compliance and patient education safety will be provided by Dr. Hawkins and/or mid-level provider (Physician Assistant). In the event that there is evidence of repetitive questionable noncompliance with prescribed medications, it is possible that you may be terminated from our practice.

"It should be noted that urine toxicology, confirmations are 95% accurate and point of care (urine dipsticks) accuracy are on average 80% accurate

Physician-Owned Laboratory Billing Process

For your convenience, we have an on-site laboratory. Urine toxicology screenings and pharmacogenetic testing may billed by our on-site Physician-Owned Laboratory. if you chose to use an outside laboratory the testing will be billed by that chosen laboratory. You will likely receive an explanation of benefits (EOB) from the laboratory. For billing questions or concerns, please contact their billing department. For any questions regarding billing from our laboratory please our office manager at 817-460-7080

Urine screen will not be performed without parental consent AND presence of parent at the time of screening.

Initial here*

That I have read or had this form read and/or had this form explained to me.

That fully understand and give consent to participate in telemedicine including the risks and benefits.

That have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Physician Assistant Consent

Hawkins Psychiatry

This facility has on staff. Physician Assistant, to assist in the delivery of medical (Psychiatric/Mental Health) care.

A Physician Assistant is not a doctor. A Physician Assistant is a graduate of a certified training program and is licensed by the state board. Under the supervision of a Physician, a Physician Assistant can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. Supervision does not require the constant physical presence of the supervising physician, but rather, overseeing the activities of accepting responsibility for the medical services provided.

A Physician Assistant may provide such medical services that are within his/her education, training, and experience. Those services may include:

Obtaining histories and performing psychiatric evaluations
Developing and implementing a treatment plan
Making psychiatric diagnosis (es)
Initiating psychiatry medication management
Making adjustments to existing psychiatric medications
Monitoring effectiveness of therapeutic interventions
Offering counseling and education
Supplying sample medications and writing prescriptions

I have read the above and hereby consent to the services of a Physician Assistant for my health care needs.

I understand that at anytime I can request the Physician Assistant consult directly with the psychiatrist physician before consenting to medication changes or changes to my treatment plan. This may be done with the physician entering the room physically and/or via telephone.

Release to Provider

You are authorized to disclose your health information to people other than yourself. Please complete all those that apply below by initialing and entering the required information

GENERAL CONSENT

Initial here*

I have read the above and certify that agree to comply with the urine toxicology protocol as written. understand that non-compliance with the above may directly affect prescription drug option in my treatment or termination from our practice.

Consent to Telepsychiatry

Hawkins Psychiatry

I understand that my healthcare provider wishes me to engage in a telemedicine consultation visit
My healthcare provider's office has explained to me how the video conference technology will be used to affect such a consultation/visit will not be the same as a direct patient healthcare provider visit due to the fact that I will not be in the same room as my healthcare provider.
I understand there are potential risks to this technology, Including interruptions, unauthorized access and technical difficulties. understand that my healthcare provider or can discontinue the telemedicine consult/visit if it is felt that the videoconferencing connections are not adequate for the situation
I further understand that will be informed of any other personnel in the room, at the time of the consultation visit and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me: (2) ask personnel to leave the telecommunication examination room and or (3) terminate the consultation at any time.
I have had the alternatives to a telemedicine consultation/visit explained to me, and in choosing to participate in a telemedicine consultation. understand that some parts of the exam involving a physical examination may not be.
I understand that billing will occur from my practitioner’s office.
Protection of Privacy: acknowledge that in order to protect my privacy, I need to choose a private location to place my telemedicine cat. I understand that in order to provide the best call environment. should reduce background light from windows or light emanating from behind me. understand that my camera should be placed on a secure, stable platform to avoid wobbling and shaking during the telemedicine session. To the extent possible, my camera should be placed at the same elevation as my eyes with my face clearly visible to the other person.
Release of Information: To facilitate the provision of care and or treatment through telemedicine, voluntarily request and authorize the disclosure of all and any part of my medical record (including oral Information) to Hawkins Psychiatry Telemedicine Providers. understand and agree that the information am authorizing to be released may include: 1) drug screen results and information about drug and alcohol use and treatment; 2) mental health information; and 3) pharmacogenetic testing results. understand that the disclosure of my medical information to Hawkins Psychiatry Telemedicine Providers, including the audio and/or video, will be by electronic transmission. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images, and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering.
Urine Drug Testing: I understand that may be required to present in-person to a laboratory for urine, blood or saliva drug testing prior to prescriptions being filled or refiled, including but not limited to benzodiazepines, stimulants, and/or sleep medications. agree to comply with this request and understand have the right to choose the laboratory. In the event refuse, understand may be terminated, referred to an alternate provider and will not be refunded for any fees paid for this telemedicine visit.

By Signing This Form I Certify:

Initial here*

That I have read or had this form read and/or had this form explained to me.

That fully understand and give consent to participate in telemedicine including the risks and benefits.

That have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Physician Assistant Consent

Hawkins Psychiatry

This facility has on staff. Physician Assistant, to assist in the delivery of medical (Psychiatric/Mental Health) care.

A Physician Assistant may provide such medical services that are within his/her education, training, and experience. Those services may include:

Obtaining histories and performing psychiatric evaluations
Developing and implementing a treatment plan
Making psychiatric diagnosis (es)
Initiating psychiatry medication management
Making adjustments to existing psychiatric medications
Monitoring effectiveness of therapeutic interventions
Offering counseling and education
Supplying sample medications and writing prescriptions

I have read the above and hereby consent to the services of a Physician Assistant for my health care needs.

Release to Provider

You are authorized to disclose your health information to people other than yourself. Please complete all those that apply below by initialing and entering the required information

GENERAL CONSENT

Initial here*

I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, genetic information, psychiatric, HIV testing, HIV results or AIDS Information.

By agreeing, my records will be released, but WITHOUT initiating, my records will NOT be released.

HEALTHCARE FACILITY/PROVIDER

Initial here*

I release my medical records to the following facility provider:

Name:

Facility:

Address:

City, State, and Zip:

Fax#:

Purpose of Release:

Attention:

Phone:

Expiration Date (if applicable)

There may be a charge for copies of records, in accordance with federal and state laws. Unless otherwise specified, authorization will expire in ONE calendar year from the date signed

Confidential Communications

Please make selections below on the best means of communication between Hawkins Psychiatry and you, our patient

Preferred Mode of Verbal Communication

Phone

Preferred Mode of Written Communication.

Required Authorization

Initial here*

I authorize Hawkins Psychiatry to use the above means of communication and, if this changes, may submit the change in writing at any time.

Designation of Representative(s)

You are authored to disclose your health information to people other than yourself as such person is involved in your healthcare or payment relating to your healthcare. By providing us with first and last name of persons below, you authorize Hawking Psychiatry to share medical information with these persons.

Patent has no representatives to report

Name:

Phone Number

Formatted text

Signature:

Date

Your information will be encrypted.