Vortex Psychiatry- Adult Intake

Prospective New Patient Demographics

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

Once we have verified your insurance benefits, a member of our staff will contact you as soon as possible to schedule your appointment. Please complete the information below.

Patient First Name

Patient Last Name

Patient Date Of Birth:

Patient Email

Patient Address (Street, City, Zip Code)

Best Contact Phone Number

Other contact phone number

Leave message on voicemail

Yes No

Leave message with person(s)

Yes No

Person name to leave message and relationship to Patient:

Reason for Appointment:

Who were you referred by?

Insurance Provider (if applicable):

Insurance Name

Insurance Subscriber or ID Number

Insurance Group Number

Please include Mental Health/Provider Services Phone Number: (Can be found on front or back of insurance ID card)

Dear Patient,

Please fill out the intake packet before the date of your appointment. Please also submit copies of all past testing, psychiatric or psychological treatment records, school/college 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

What may be the underlying reason for the problems? Are there any psychological, medical, neurological, or genetic problems underlying the condition? Do the problems present a psychiatric disorder or a variant of normal behavior? What can be done to address the problems and what will happen if we do nothing?

The initial evaluation takes approximately one hour, sometimes longer and consists of:

Patient and family 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 charge an annual fee of $69.00 at your first date of service, and once a year thereafter.

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

Warm Regards,

Said A. Ibrahimi M.D.

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. We are available by email at vortexpsychiatry@outlook.com.
Charges indicated below indicate the cancellation of appointments with less than 1 business-day notice and or same day no show/cancellation. 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.
Fees are as follows for no call- no show- less than 24 hours-notice to cancel or reschedule your appointment.1st occurrence No Fee
2nd and all occurrence after the first waiver is: $175.00
We use an email reminder service for your upcoming appointment. The reminders will come via email and or an auto remind service. Please check your junk/spam email box as well.
After the 4th occurrence potential discharge of care from Dr. Ibrahimi. Per Dr. Ibrahimi's discretion.
You may email us about yourself or the patient if you wish. Please clearly indicate the patient’s name and date of birth and best contact number. All emails will be responded to within -1-2 business days. The doctor reviews emails daily in most cases. If it is urgent, please call the office instead of emailing at 925- 648-2650. Standard emails are not hack proof but are considered HIPAA compliant.
Refills are done using electronics means. This is secure and avoids errors. Please do not call the office for refills. Visit our website to view our medication refill policy.
Most prescription refills will require regular follow-up as suggested by the doctor. Medication refill requests must be made in writing via website or email.
For medication refills can take the minimum 3-5 business days to be viewed and process. Please see our website for full details regarding Refill Request.

Patient (please sign):

If you will be using your medical insurance to pay for visits to this office….

Insurance coverage is for a particular doctor - not the office.
If your insurance changes, let us know immediately. Transactions older than 60 days cannot be billed to insurance unless your insurance policy is indicates rebilling up to 12 months from date of service.
If you have dual coverage, it is the Patient's responsibility to notify Vortex Psychiatry.
We require a credit card on file for timely payment of amount due to this office for all unpaid charges.
We do not verify your coverage. This is your responsibility.
If your insurance denies coverage, you are responsible for services rendered.
Please check with your insurance as to what your deductible is. You are expected to pay the contracted rate at the time of service. We require full payment of agreed upon rate at time of visit if you have not met your deductible.
Phone consultations over 10 minutes are charged as a full visit with Dr. Ibrahimi. Your insurance most likely will not cover these.
Some services such as phone consultations with other providers, review of records, no-show charges, cancellation fees, form filling, reports etc. are often NOT a reimbursable expense. If these services are used or requested by you, you are responsible for their charge.
If after billing your insurance company we find that you do not have coverage, have not met the deductible, or for any other reason, the amount due will be charged to your credit card on file after 30 days.
Please call your insurance and make certain that you are covered for seeing this office, the doctor with whom you have the appointment and clearly understand your deductibles and your coverage.

Insured’s Signature

Please read carefully and sign. This is a required form if you want us to bill your insurance.

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:

Dear Patients,

This letter is to inform you of our updated billing practice regarding receiving patient payments. Effective June 2022, we now require a credit or debit card to be on file with our office or full patient payment of services at each appointment.

Why the change? There are several reasons for this change. With the changing environment in healthcare, in particular the Affordable Care Act and High Deductible Health Plans (HDHPs) more responsibility of payment is being placed on the patient. We need to be sure that patient balances are paid in a timely manner. To do this, we need to ensure we have a guarantee of payment on file in our office.

What is a Deductible and How Does It Affect Me? An annual deductible is the dollar amount you must pay out of pocket during the year for medical expenses before your insurance coverage begins to pay. For example, if your policy has a $2,000 deductible, you must pay the first $2,000 of medical expenses before the insurance company begins to pay for any services. This works just like the deductible for your car insurance or homeowner’s insurance policy does.

When do I have to pay for services? Any time you receive medical care, you will be expected to pay in full for your services until your deductible is met. If you have a very large deductible, called a high-deductible insurance plan, you may have to pay out of pocket for most of your primary care services.

How will I know when my deductible has been met? You can call your insurance company at any time to check on how much of your deductible has been met and some insurance companies have this information available online. Every time you receive medical services, you will receive notification from your insurance company with how much they paid or did not pay if the amount went to your deductible when they send you an Explanation of Benefits (EOB.)

How will I know how much you are going to charge me? You will receive a letter in the mail (or e-mail) from your insurance carrier that explains how much of your office visit they pay and how much you pay. This is called an Explanation of Benefits (EOB.) This letter tells you exactly, according to your health insurance coverage, how much of your health care bill is your responsibility and how much is the responsibility of your insurance to pay.

Then what? We receive the same Explanation of Benefits (EOB) that you do. Most Insurances will send your EOB prior to us receiving our copy. An EOP can arrive 30-60 days after your appointment has been billed. We look at each EOB carefully and determine what your insurance has determined as patient responsibility. This is the same way we normally determine how much to send you a statement for in the mail.

All patients with commercial insurance are required to keep a credit or debit card on file. If you do not wish to keep a card on file, we will expect an estimated payment at the time of service. For example, if your commercial insurance requires $175.00 to be paid for standard service and your deductible is not met, you will be expected to pay the $175.00 via debit or credit card before you are seen, but this will not include ancillary charges that may arise out of your visit. Once we receive the Explanation of Benefits (EOB) on your visit, we will send a statement if your patient responsibility is higher than the originally collected amount or you will have a credit on your account if your patient responsibility is lower than the originally collected amount.

Once we receive the insurance EOB for your visit, we will charge the credit card on file the exact amount as per the EOB that is stated to be patient responsibility. Once charged, we will email you a receipt of payment.

The other items that can be charged are no-show charges, and unpaid copays

Patient Signature:

Date

Financial Information

(To be completed by patient or caretaker prior to first appointment)

Name that appears on credit card

Credit Card Type

VISA/MC/AMEX/DISCOVER

Credit Card Number

Credit Card Expiration Date

CVV

Credit Card Zip Code

Financial Responsibility

Financial Responsible: First and Last Name

Financial Responsible Date of Birth:

Address

City

State

Zip

Best Contact Phone:

Email address:

The office will keep a current credit card on file. I allow the office to charge fees not coverable by the insurance such as for non-coverage, yearly admin charge, unmet deductibles, unpaid copays, and no-show charges. A statement of such charges will be sent to you.

I agree to pay all bills as presented and all reasonable fees associated at the time with the collection of such charges including fees for returned checks, rush prescription, yearly admin charges, copays, phone consultation charges not covered by insurance, same day cancellation and no-show fees, request for copy of records, school form filling etc. per schedule of fees attached currently in force.

Signature

Date

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

List the reason(s) for seeking help at this time (when started):

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

Your Primary Care Physician:

Provider Name

Provider Phone:

Address

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? Type Yes or No

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 Left

Additional Medical Information

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

Is this evaluation part of the worker’s compensation proceedings?

Yes No

If yes, please describe

ADULT RATING SCALE

First Name

Last Name

DOB

Age

Major concerns (check all that apply):

Attention

Relationships

Professional

Health

Memory and thinking

Other (please specify)

Please rate these behaviors: 0 – Never (None) 1 – Sometimes (Mild) 2 – Often/Always (Severe)

(circle the most appropriate number)

Block I

Can't start a task

0 1 2

Hard to stay focused, easily distracted

0 1 2

Poor attention to details, careless mistakes

0 1 2

Forgetful, losing things

0 1 2

Poor planning, procrastination

0 1 2

Daydreaming

0 1 2

Leaving work unfinished

0 1 2

Impulsive decisions

0 1 2

Interrupting conversations

0 1 2

Acting before thinking

0 1 2

Fidgeting, shaking legs

0 1 2

Talking excessively

0 1 2

Moving constantly, changing positions

0 1 2

Hard to stay seated

0 1 2

Liking sameness, routine

0 1 2

Rigid and stubborn

0 1 2

Transitions are difficult

0 1 2

Perfectionist, works slow

0 1 2

Concerns about order and neatness

0 1 2

Block II

Gets into heated arguments

0 1 2

Losing temper, getting angry

0 1 2

Feelings are hurt, gets easily frustrated

0 1 2

Going through uncontrollable rages

0 1 2

Conflicts with authorities

0 1 2

Problems with the law

0 1 2

Arrests, DUI (details in few words)

0 1 2

Smoking cigarettes

0 1 2

Excessive drinking

0 1 2

Other drugs (legal and illegal), details

Block III

Nervous habits or tics

0 1 2

(describe)

Obsessive, intrusive thoughts or images

0 1 2

Compulsive behaviors

0 1 2

Storing things, not able to discard them

0 1 2

Excessive superstitions

0 1 2

Block IV

Worrying excessively about everything

0 1 2

Feeling tense, keyed up

0 1 2

Unable to stop worrying

0 1 2

Self-conscious , feelings easily hurt

0 1 2

Easily embarrassed, sensitive to criticism

0 1 2

Panic attacks

0 1 2

Panic attacks

0 1 2

Excessive fears (crowd, heights, etc.)

0 1 2

Nervous stomach, headaches

0 1 2

Family history of anxiety, panic, and social phobia

0 1 2

Excessive tiredness and daytime sleepiness

0 1 2

Always tired, hard to stay alert

0 1 2

Block V

Unhappy most of the day, most days

0 1 2

Crying

0 1 2

Thoughts of dying

0 1 2

Feeling guilty, being too hard on self

0 1 2

Feels things will never get better

0 1 2

Not enjoying anything anymore

0 1 2

Major changes in sleep and appetite

0 1 2

Feeling worthless, inferior (e.g. I am stupid)

0 1 2

Feeling that be better off dead

0 1 2

Thoughts of suicide

0 1 2

Feeling giddy, witty and funny

0 1 2

Mood changes quickly, drastically

0 1 2

Episodes of being talkative, pressure to talk

0 1 2

Periods of extreme energy alternating with periods of excessive tiredness and calm

0 1 2

Acting recklessly

0 1 2

Thinking more about romance and sex

0 1 2

Family history of depression or bipolar disorder

0 1 2

Block VI

Feeling indifferent, not caring

0 1 2

Loosing interest in thinks that liked before

0 1 2

Feeling drained of energy

0 1 2

Not seeing friends, mostly alone

0 1 2

Sleeps too much, always tired

0 1 2

Block VII

Sleep is disturbed, interrupted

0 1 2

Hard time falling asleep

0 1 2

Sleepwalking, -talking, night terrors

0 1 2

Block VIII

Hearing what others can't hear

0 1 2

Feeling others are out to get you

0 1 2

Strange, bizarre, intrusive thoughts

0 1 2

Being suspicious

0 1 2

Block IX

Change in appetite

Up Down

Weight

Loss or Gain

Recent

Vision Loss or Hearing loss

Recent change in health (describe)

Additional Comments:

Person(s) helping with the questionnaire:

Message to our patients about Arbitration

The attached contract is an arbitration agreement. By signing this agreement, we are agreeing that any dispute arising out of the medical services you receive is to be resolved in binding arbitration rather than a suit in court. Lawsuits are something that no one anticipates, and everyone hopes to avoid. We believe that the method of resolving disputes by arbitration is one of the fairest systems for both healthcare providers and their courts. Arbitration agreements between patients and physicians have long been recognized and approved by the State of California. By signing this agreement, yon are changing the place where your claim will be presented. You still can call witnesses and present evidence. Each party selects an arbitrator (party arbitrators), arbitrator. These three arbitrators hear the case. This agreement generally helps to limit the legal costs for both the patients and physicians. This is because the time it takes to conduct an arbitration hearing is far less than for a jury trial. Further, both parties are spared some of the rigors of a trial and the publicity which may accompany judicial proceeding.

Our goal, of course, is to provide medical care in such a way as to avoid any such dispute. We are all caring doctors and do our utmost to be responsive. We know that most problems begin with communication. Therefore, if you have any questions about your care, please ask us.

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