Request an Initial Appointment

Emergency Assistance

If this is an emergency, call 911 or go to your nearest Emergency Room

Submission of this form does not guarantee acceptance as a patient nor does it create any form of provider-patient relationship. We will call you to discuss next steps, hopefully within a week.

Note that the more information you can provide, the better we are able to assist you.

Patient Information

First name

Last name

Date of Birth

Phone number

Email address

City you live in

City you work in

If I am unable to accept you as a patient at this time, would you like associated providers to review your information for potential acceptance? Your information will remain confidential. These providers can be found at soundmindpsychiatry.com/our-providers-and-staff

No, I only want to see Nancy Wagner Yes, I'm willing to see a provider of either gender Yes. I want to see a female provider, but am willing to see a male provider if no female providers can see me. Yes, but only female providers

By checking this box, no male providers will be considered for your care.

Please Upload a Drivers License In order to schedule your first appointment, we need a copy of your drivers license in order to verify identity. This information is kept STRICTLY confidential.

Add file

Please upload a file

I understand Nancy Wagner's primary role is prescribing and managing medication. While Nancy may incorporate some psychotherapy interventions into medication management appointments, this is not meant to be a substitute for individual psychotherapy with a licensed therapist.

I understand that Nancy Wagner does not offer ADHD coaching or neuropsychological assessments, although she may offer referrals for those services.

Insurance Information

Insurance ID Number

Please include your alpha prefix, if appropriate

Group Number

I understand that most appointments will be conducted remotely via video teleconferencing but an in-person appointment may be required

Video teleconferencing appointments are also known as Synchronous Telemedicine. When you call your insurance compay to check on your mental health benefits, you should specifically ask about these benefits, and check that the provider(s) you are interested in seeing will be covered for this benefit.

Please upload a photo of the FRONT of your insurance card This information will be kept strictly confidential

Add file

Please upload a file

Please upload a photo of the BACK of your insurance card This information will be kept strictly confidential

Add file

Please upload a file

About Your Request

What are the issues, concerns, etc. that you would like to receive medication management for?

Please be as specific as possible. (Example: Depression, Anxiety, etc.) Please also let us know how long this has been an issue for you

Please list ALL the medications you are currently taking, including prescription medications, over the counter medications, and supplements

What psychiatric medications have you taken previously?

If applicable, what is your current prescribing provider’s name?

If applicable, what is your current talk therapist / counselor's name?

Have you ever been hospitalized for psychiatric purposes?

Yes No

If yes, please note approximate dates, durations, and whether the stay was voluntary or involuntary.

Do you have history of substance use concerns? (ex: drugs, alcohol, food)

Yes No

If yes, was / is this drugs, alcohol, or food? Please include approximate dates if in the past.

Have you ever self-harmed?

Yes No

If yes, please note approximate dates.

Have you ever attempted suicide?

Yes No

If yes, please note approximate dates.

Do you currently have suicidal thoughts?

Yes No

If yes, please note frequency and intensity.

Are there any legal issues you are dealing with? (Ex: divorce, restraining order, lawsuit, etc.)

Yes No

If yes, what is it, and is this current or in the past?

Do you have any history of violent actions? (Ex: Throwing things, punching walls, road rage, physical fights, etc.)

Yes No

If yes, was this in the past or present?

Referral Information

If you were referred by someone, please type their first and last name

Good Faith Estimate & Fee Disclosure (For Out-of-Network Patients)

Due to a new law, starting January 1, 2022, healthcare providers are now responsible for providing a "good faith estimate" of medical fees related to your treatment. The aim of the new law is to increase transparency of medical costs and to reduce "surprise billing". The following explains my out-of-network fees ("private pay fees") and your rights as a consumer of healthcare services.

Nancy Wagner, ARNP, PMHNP-BC
2105 112th Ave NE, Suite 201, Bellevue, WA 98004
Phone: 425.968.5948
NPI: 1326493891
EIN: 81-5365590

Patient's Full Name (First and Last)

Patient's Date of Birth

Primary Services Provided and Associated Fees

Office visit, evaluation and management, new patient, 60 min CPT 99205 - $400
Office visit (level 3), evaluation and management, established patient, 30 min, CPT 99214 - $135
Office visit (level 4), evaluation and management, established patient, 40 min, CPT 99215 - $185
Prolonged services, with or without direct patient contact, each additional 15 min CPT 99417 - $50
Add-on psychotherapy, 16 min CPT 90833 - $85
Brief behavioral assessment CPT 96127 - $10

Other Services and Fees *Due to the unpredictable nature of each patient’s needs these fees will not be included in the GFE. This information serves as notice of additional fees you may incur based on your personal needs*

Letters/forms completed outside of appointments - $220/hour billed in 15 min increments
Medication refill (outside of visits)- $25
Missed/late-reschedule appointment (<48 hours notice, not including weekends) - $100 (follow up)/$300 (intake)
Portal messaging - $50-150 depending on time/complexity
Communication with your legal team - $500/hour billed in 15 min increments
Court subpoena - $1000/hour with 8 hour minimum
Communication with your other providers - $220/hour billed in 15 min increments

Frequency and Duration of Treatment

Depending on your treatment needs, services will be provided for a frequency of one of the following and may fluctuate throughout the duration of treatment:

Weekly
Bi-weekly
Monthly
Every 2-3 months for maintenance treatment

Mental health treatment is an extremely personal experience tailored to the needs of the patient and the presenting concerns. Due to the nature of this unpredictability and Nancy Wagner, ARNP, PMHNP-BC’s commitment to meeting and catering to the needs of every patient individually, determining duration of treatment is ethically impossible. The industry standard of most Health Insurance companies is 12-15 visits. You and your psychiatric nurse practitioner will continue to review progress and make personalized decisions regarding both the frequency and duration of treatment periodically. You can decide at any time to terminate services. Due to this, all GFE’s will be based on your current frequency over the course of a 12 month/52-week calendar year)

Diagnoses Used *Please note diagnostic codes provided here are generic and used to satisfy the requirements of the No Surprises Act. Any other diagnoses will be discussed between patient and psychiatric nurse practitioner for the purpose of treatment planning and referrals to other appropriate providers*

F43.21 Adjustment Disorder with Depressed Mood

F41.1 Panic Disorder

F43.23 Adjustment Disorder with Mixed Anxiety and Depressed Mood

F99.00 Mental Disorder, not otherwise specified

F90.2 Attention Deficit Hyperactivity Disorder, combined type

F41.1 Generalized Anxiety Disorder

G47 Insomnia, unspecified

F32.9 Major Depressive Disorder, Single Episode, Unspecified

R41.840 Attention and concentration deficit

Health Insurance Waiver

You understand that Nancy Wagner, ARNP, PMHNP-BC is an out of network provider for all insurance plans except for select plans under Premera, Regence, Aetna, and First Choice. You understand you are waiving the usage of your insurance if Nancy Wagner, ARNP, PMHNP-BC is not in network with your insurance plan.. You are, however, more than welcome to use your HSA/FSA accounts for payment. You are responsible for understanding your own insurance benefits to include the co-pays and deductibles coverages available to you by choosing to work with a mental health provider within your insurance company’s network. Those amounts may or may not be less than the fees you are agreeing to pay Nancy Wagner, ARNP, PMHNP-BC. In the event that you are not covered by an insurance plan that Nancy Wagner, ARNP, PMHNP-BC is in network with, you understand you will be responsible for paying the out-of-pocket fees as listed above and waiving your insurance benefits.

At any time, you may request Out of Network Billing statement(s) from Nancy Wagner, ARNP, PMHNP-BC. This statement will include Dates of Service, Billing Codes, and Diagnostic Codes. You may choose to submit these statement(s) to your insurance company in an effort to request full or partial reimbursement. You understand that the reimbursement decision is that solely of your insurance provider and Nancy Wagner, ARNP, PMHNP-BC in no way guarantees or has authority in this reimbursement decision.

Cost Estimation

Initial visit fee is _$400.
Fee per 30 minute follow up visit is $_220__. Towards the beginning of treatment, visits occur bi-weekly to monthly. Based on the industry standard of most health insurance companies of 12-15 follow up visits per 52-week calendar year, the total estimated cost of treatment, not including holidays, breaks, and other unpredictable fees/services disclosed above, will be $_3,700__.
Please note: If your condition worsens, you may require more frequent follow up visits, in which case your personal cost estimation will increase. As always, you are free to terminate services and/or seek care with an in-network provider.

Disclaimer: This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 1-800-985-3059.. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

Today's Date

Your information will be encrypted.