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Medicaid Statement
Please note that we are NOT a Medicaid provider. By clicking the box below you are acknowledging that you DO NOT have Medicaid as either a primary OR secondary insurance.
Do you have Medicaid?
*
NO
Payment Type
Will you be using insurance?
*
Yes
No
Please ensure you have discussed the self-pay rates with our intake department as they may have changed.
Health Insurance
Do you have Medicare?
*
YES
NO
Do you have TRICARE?
*
YES
NO
Are you the sponsor?
*
Yes
No
Sponsor First Name
*
Middle Initial
Sponsor Last Name
*
Sponsor SSN
*
Sponsor Date of birth
*
+
TRICARE is secondary to all other insurances and will not pay if we are not in network with your OHI provider. This will result in the Responsible Party receiving a bill for services regardless if you have TRICARE or not. Please confirm you do not have OHI.
Do you have other health insurance (OHI)?
*
YES
NO
Do you have Tricare for Life?
*
YES
NO
Select your insurance below. If you do not see your insurance listed, please contact our office as we may not be in network with your insurance company.
*
Aetna
America's Choice Provider Network
Allianz Global Assistance
Anthem BC/BS
Cigna
ChampVA
Employee Benefits Management Services
Humana
Magellan
Medicare Part B
Mediplus
Meritain Health
Selman & Company
TRICARE
TRICARE for Life
TRIWEST
UMR
UBH
UHC
United Health One
Do you have another insurance?
*
Yes
No
Select your insurance below. If you do not see your insurance listed, please contact our office as we may not be in network with your insurance company.
*
Aetna
America's Choice Provider Network
Allianz Global Assistance
Anthem BC/BS
Cigna
ChampVA
Employee Benefits Management Services
Humana
Magellan
Medicare Part B
Mediplus
Meritain Health
Selman & Company
TRICARE
TRICARE for Life
TRIWEST
UMR
UBH
UHC
United Health One
Do you have another insurance?
*
Yes
No
Select your insurance below. If you do not see your insurance listed, please contact our office as we may not be in network with your insurance company.
*
Aetna
America's Choice Provider Network
Allianz Global Assistance
Anthem BC/BS
Cigna
ChampVA
Employee Benefits Management Services
Humana
Magellan
Medicare Part B
Mediplus
Meritain Health
Selman & Company
TRICARE
TRICARE for Life
TRIWEST
UMR
UBH
UHC
United Health One
Do you have another insurance?
*
Yes
No
Select your insurance below. If you do not see your insurance listed, please contact our office as we may not be in network with your insurance company.
*
Aetna
America's Choice Provider Network
Allianz Global Assistance
Anthem BC/BS
Cigna
ChampVA
Employee Benefits Management Services
Humana
Magellan
Medicare Part B
Mediplus
Meritain Health
Selman & Company
TRICARE
TRICARE for Life
TRIWEST
UMR
UBH
UHC
United Health One
Please upload a copy of the front and back of your commercial insurance card. Do not upload any military ID cards.
*
I do not have OHI.
*
-
Adult Intake Form
First Name
*
Middle Initial
Last Name
*
Patient SSN
*
Sponsor or Subscriber SSN
*
Date of birth
*
+
Age
*
Gender
*
Male
Female
Street Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
What is the preferred number to reach you at?
*
Home
Cell
Work
Other
Phone Number
*
Would you like to add another contact number?
*
Yes
No
Phone Number
Best time to call
*
7:30 - 9:00
9:00 - 12:00
12:00 - 3:00
3:00 - 5:00
Email Address
*
Emergency contact information
Name
Phone number
Relationship
1
Name
Phone number
Relationship
2
Name
Phone number
Relationship
Responsible Financial Party
We require a credit card to be placed on file. Cards are securely filed and will be used only for payment of co-pays, co-insurance, payments for service and no-show fees. Credit card information must be entered even if you are not the responsible party.
TRICARE Prime and Active Duty Service Member will not be charged a co-pay but must still put card information for any no-show fees.
In order for us to verify the credit card information, we will run a $.01 transaction and then immediately void this transaction. By checking the box below, you agree that we may charge the card for this transaction.
*
I agree
Is financial responsibility someone other than the patient?
*
Yes
No
Name on Card
*
Credit Card Type
*
Visa
MasterCard
American Express
Discover
Credit Card Number
*
Expiration Date (mm/yy)
*
Security Code
*
By checking the box below, you agree that we may charge the card provided for the amount owed the day after it is reflected on the account.
*
I agree
First Name
*
Last Name
*
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Home Phone Number
Work Phone Number
Cell Phone Number
*
Email address
*
Referral Information
Who referred you to Family Care Center?
*
Name and number of your primary care physician if known?
Name and number of therapist if known?
Presenting Problem
What are the problems or concerns you are having?
*
When did the problem begin and for how long has it gone on?
*
Are you being scheduled for TMS?
*
Yes
No
TMS Screening Tools
TMS Consent Form
You must read the consent form before proceeding. By checking this box, you acknowledge that you have read the TMS Consent for Treatment.
*
Agree
TMS Screening Questionnaire
*
No
Yes
Have you ever had an adverse reaction to TMS?
No
Yes
Have you ever had a seizure?
No
Yes
Have you ever had an EEG
No
Yes
Have you ever had a stroke?
No
Yes
Have you ever had a head injury (include neurosurgery)?
No
Yes
Do you have an metal in your head?
No
Yes
Do you have any implanted devices such as cardiac pacemakers, medical pumps, or intracardiac lines?
No
Yes
Do you suffer from severe headaches?
No
Yes
Have you ever had any other brain-related condition?
No
Yes
Have you ever had any illness that caused brain injury?
No
Yes
Are you taking any medications?
No
Yes
If you are a woman of childbearing age, are you sexually active, and if so, are you using a reliable method of birth control?
No
Yes
Does anyone in your family have epilepsy?
No
Yes
Do you need further explanation of TMS and its associated risk?
No
Yes
PHQ-9
*
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
Not at all
Several days
More than half the days
Nearly every day
Trouble falling or staying asleep, or sleeping too much
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself, or that you are a failure or have let yourself or your family down
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching TV
Not at all
Several days
More than half the days
Nearly every day
Moving or speaking so slowly that other people could have noticed? Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
Not at all
Several days
More than half the days
Nearly every day
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 alowng with other people?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Medication History
*
Medication
Dosage
Duration
Response (please note if discontinued due to side effects)
Medication 1
Medication
Dosage
Duration
Response (please note if discontinued due to side effects)
Medication 2
Medication
Dosage
Duration
Response (please note if discontinued due to side effects)
Medication 3
Medication
Dosage
Duration
Response (please note if discontinued due to side effects)
Medication 4
Medication
Dosage
Duration
Response (please note if discontinued due to side effects)
Medication 5
Medication
Dosage
Duration
Response (please note if discontinued due to side effects)
Medication 6
Medication
Dosage
Duration
Response (please note if discontinued due to side effects)
Treatment History
Prior
OUTPATIENT
psychotherapy?
*
Yes
No
How many times?
Dates if known.
+
-
Diagnosis
*
Therapist information
Name
City, State
Phone number
1
Name
City, State
Phone number
2
Name
City, State
Phone number
3
Name
City, State
Phone number
4
Name
City, State
Phone number
5
Name
City, State
Phone number
Treatment Modality (check all that apply)
Cognitive Processing Therapy
Cognitive Behavioral Therapy
EMDR
Prolonged Exposure
Dialectical Behavioral Therapy
Not Known
Other
Other
Which, if any, were beneficial?
Has any family member had any mental health treatment?
*
Yes
No
Who and for what reason or diagnosis and where they given any medications? (list all here)
Notices
Family Care Center Notices
By checking this box, you acknowledge that you have read the notices.
*
Agree
I have read the financial agreement.
*
Yes
I have read the no-show policy.
*
Yes
Acknowledgement and Signature
By signing this form, you agree that you are willing to be seen by a provider at the Family Care Center and will become a client of this clinic upon submission of this form. Clients are responsible for all payments at time of service. Clients who do not show up for their initial medication appointment are subject to a $100 no-show fee. Furthermore, clients who miss a follow-up appointment for medications are subject to a $100 no-show fee. Clients are also charged a $50 no-show fee for missed therapy appointments. These fees must be paid prior to any further appointments being made. Two or more no-shows for an initial appointment can result in you not being accepted as a client.
*
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