Vortex Psychiatry- Personal Injury

New Patient Demographics

In preparation for your first visit with Said A. Ibrahimi, M.D., Vortex Psychiatry, we will need some information.

Patient First and Last Name

Patient Social Security Number

Patient Date Of Birth:

Patient Email

Patient Address (Street)

Patient Address (City and Zip Code)

Best Contact Phone Number

Leave message on voicemail

Yes No

Personal Injury

Name of Law Firm

Law Firm Phone Number

Attorney Name

Attorney Name Phone Number

Attorney Email

Date of Injury/Incident

Dear Patient,

Please fill out the intake packet before the date of your appointment. You and your Attorney will be required to sign a lien via electronic or PDF format. Prior to your appointment, please also submit copies of all past testing, psychiatric or psychological treatment records, and psychiatric inpatient records/discharge summaries, if applicable.

About the evaluation

There are no standard psychological or laboratory tests by which one can make a psychiatric diagnosis. The diagnosis is made by listening to the presenting concerns, going over the records, reviewing the family and patient's history, conducting interviews with the patient, the family, and others, if necessary.

The initial evaluation will help you determine

The initial evaluation takes approximately up to 60 minutes

Patient interview
Discussion of findings and presentation of diagnostic impression
Treatment recommendations

The evaluation will give you a good understanding of what's going on. There are many ways to deal with the problems. Many patients and the families are uncomfortable about psychiatric medications. We want you to know that medications are not always recommended and often are not even appropriate. The decision about the medication depends on the nature and severity of the problems, the patient's age, associated issues, but ultimately, on the best available treatment option.

If a medication is prescribed, you will be scheduled for follow-up appointments in one week to one month in time, depending on the problems and the prescribed medication(s).

We look forward to seeing you and hope that we can be of service.

Warm Regards,

Said A. Ibrahimi M.D., QME

Vortex Psychiatry

Office Policies and HIPAA Policy Acknowledgement

Our HIPAA policy is posted on our website: www.VortexPsychiatry.com Please be sure to read it.
The office staff is available to answer your call from 8 AM to 4 PM. Monday to Thursday. Our phone lines are closed on Friday's. We are available by email at legal@vortexpsychiatry.com

Patient Signature

Contract for Controlled Substances

Controlled substance medications (i.e., benzodiazepines and stimulants) are very useful. However, they have potential for misuse and therefore are controlled by local, state, and federal authorities. Because my provider is prescribing such medications for me, I agree to the following conditions:

I am responsible for the controlled substance medications prescribed to me. If my prescriptions and/or medication are misplaced, stolen, or if “I run out early”, I understand that this medication will not be replaced regardless of the circumstances.
I will not request or accept controlled substance medication from any other physician or individual while I am receiving such medication from Vortex Psychiatry. Besides being illegal to do so, it may endanger my health. I understand that if I violate any of the above conditions, my prescriptions for controlled medications may be terminated immediately. If the violation involves the concomitant use of nonprescription or illicit (illegal) drugs, I may also be reported to other physicians, pharmacies, medical facilities, and the appropriate authorities.
I am aware that all requests for prescriptions must be in writing during business hours. a) I am responsible for taking the medication in the dose prescribed and for keeping track of the amount remaining. Renewals are based upon keeping scheduled appointments. b) Refills will not be made as an “emergency”. No controlled medications can be ordered when the office is closed. I understand the importance of following my treatment plan as directed by my physician and agree to keep my scheduled appointments.
I understand that if I violate this controlled substance contract due to non-compliance of medical directions, such as: failure in taking medications as prescribed, utilizing other illicit drugs, obtaining similar medications from others, or abuse of controlled medications, I may be subject to dismissal from this practice.
I understand that the main treatment goal is to improve my ability to function. I am being given potent medication to help me reach that goal and agree to help myself by following better health habits. I understand that using illicit drugs will negatively impact my progress. Continued use of illegal or illicit substances after warning can be cause for termination of medical care and reporting to authorities.

I have read this contract and fully understand its content and the consequences of violating this contract. By signing below, I accept the above treatment agreement.

Patient Signature:

Date:

No Show Policy:

Our policy is as follows:

We charge for all changes and cancellation of appointments with less than 1 business-day notice of $1200.00. There are no exceptions for this (including sickness, work travel, etc.) This is a typical policy for psychiatric office where a considerable time is set aside with no double booking. Should you need to inform us of your cancellation, during or after business hours, you can notify Vortex Psychiatry via email at: legal@vortexpsychiatry.com or by phone: (925) 648-2650. We understand there are unforeseen events that may occur.

After the 4th occurrence potential discharge of care from Vortex Psychiatry, per Dr. Ibrahimi's discretion.

Medication Refill Request Policy:

Before you request a refill request, please read:
We suggest keeping a 7-day supply of your medication in a separate bottle to avoid last-minute requests. All refill requests can take up to a MINIMUM of 3 business days to be received and viewed. They are typically filled within 3-5 business days (Monday – Thursday only) Please allow this much time for unforeseen issues. Please make your balance payment and schedule your follow up appointment prior to refill request to avoid further delays. We do not offer rush refill request.

Before a refill request is sent please ensure:

Your next appointment has been scheduled.
1. No refills are processed on nonbusiness days such as Fridays or over the weekend. NO EXCEPTION. Refill requests are viewed and processed Monday Through Thursday only.
All refill requests must be submitted through this link. We do not accept refill requests over the telephone.
- We ask that you please make all requests for medication to this link, and do not go through your pharmacy to request medications. Often, the requests from the pharmacy do not go through and can cause delays in getting your medication.
Should you need an appointment contact our office Monday – Thursday 9 am -4 pm Vortex Psychiatry at 925-648-2650 You can also email us at legal@vortexpsychiatry.com.com Our phone lines are closed on Fridays.
Not having an appointment will delay and hinder your ability to get your medication. Refill requests will be denied if you do not have an upcoming appointment/balanced paid in full.
Please make sure you are being seen regularly and do not miss any appointments. We will try our best to accommodate your appointment day and time of choice.

Signature required for acknowledgement.

Relationship to patient (if other than patient)

*Contact information of a person completing this form if not a patient

Name

Best contact phone:

Email:

Relationship to a patient

Explain Incident/Injury/Accident. Include all details and Date of Inury

Did you go to the Emergency Room?

Did the police and an ambulance arrive at the scene of injury/incident?

Have you seen other specialists for these problems/symptoms? (Approximate Dates)

What ongoing symptoms have you been experiencing since the accident/injury?

What ongoing symptoms have you been experiencing since the not related to accident/injury?

Your Primary Care Physician:

Provider Name

Provider Phone:

Address, City , State, Zip Code

Other Physicians and Therapists currently involved in your care

Provider Name

Specialty

Provider Phone

Provider Name

Specialty

Provider Phone

MEDICAL HISTORY

How would you rate your general health?

Excellent

Good

Fair

Not so good

Very bad

Do you have serious or chronic medical conditions, accidents, or injuries, including head injuries?

Yes No

Please describe

Medications:

Please list all current medications, including vitamins and supplements

Have you had allergic reaction to any medication?

Yes No

What medications and extent of reaction

Recently, did you have unexplained?

Weight Loss Weight Gain

Recently, did you have unexplained?

Big change in appetite Increase or decrease

Big change in sleep pattern (briefly describe)

Big change in alertness and energy during the day (briefly explain)

History of medical and psychiatric hospitalizations

Medical and psychiatric hospitalizations

MEDICAL HISTORY:

Please check all that applies

Do you wear hearing aid?

Yes No

Do you wear glasses?

Yes No

Date of last menstrual period

Are you right or left-handed?

Right

Yes/No

Left

Yes/No

Please indicate any additional medical information, symptoms, and comments that you would like to discuss with Dr. Ibrahimi during your initial evaluation.

Health Habits

Alcohol and Other Drug use:

Do you drink, smoke, or use other (non-prescribed and non-OTC) drugs?

If yes, please answer the following questions.

Other (please specify)

What are your drink(s)/drug of choice?

Alcohol Other Drugs

How much do you drink or use per day/week?

Alcohol Other Drugs

Do you feel you have problems with alcohol or drugs?

Alcohol Other Drugs

Have you ever had a DUI or other drug related problems?

Alcohol Other Drugs

Has your drinking and/or drug use ever caused problems in the family, work, or in in your relationship(s)?

Alcohol Other Drugs

Previous treatment programs (dates and locations if possible)

LEGAL HISTORY:

(use additional space if needed)

Have you ever had any legal difficulties/problems or previous imprisonment?

Yes No

If yes, please describe

Major concerns (check all that apply):

Attention

Relationships

Professional

Health

Memory and thinking

Notice Of Doctor's Lien----Patient Signature

I do hereby authorize Vortex Psychiatry (Said A Ibrahimi MD) to furnish you, my attorney, with a full report of his examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was recently involved. I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as may be due and owing him for medical service rendered me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect and fully compensate said doctor. And I hereby further give a lien on my case to said doctor against any and all proceeds of my settlement, judgment or verdict which may be paid to you, my attorney, or myself, as the result of the injuries for which I have been treated or injuries in connection therewith. I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered me and that this agreement is made solely for said doctor’s additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. I agree to promptly notify said doctor of any change or addition of attorney(s) used by me in connection with this accident, and I instruct my attorney to do the same and promptly deliver a copy of this lien to any substituted or added attorney(s). Please acknowledge this letter by signing below and returning to the doctor’s office. I have been advised that if my attorney does not wish to cooperate in protecting the doctor’s interest, the doctor will not await payment but may declare the entire balance due and payable. I further direct my attorney to pay said doctor one hundred percent of all medical costs associated with my treatment. I understand all costs associated with my care and believe them to be necessary, reasonable, and customary.The undersigned, being attorney of record for the above patient, does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect and fully compensate said doctor above named. The attorney further agrees that in the event this lien is litigated the prevailing party will be awarded attorney fees and costs.

Signature

Date

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