New Patient Full Forms

New Patient Packet (FULL)

If you have scheduled a New Patient Appointment, kindly please complete a New Patient Packet. This form is required prior to your initial appointment.

If you have NOT scheduled a new patient appointment you may also complete this form. The receipt of this form will alert a member of our staff to call you.

This form is fully online, there is no need to print it out, scan or email. Once you complete it, the form comes directly to our staff.

Before you complete this form:

* Please allow 15-20 minutes to complete.
* Complete the from on a computer.
* Have your insurance card handy.
* Have a list of your medications available.

Insurance Company Name (may be different than medical) *

Subscriber ID *

Insurance Phone Number *

Subscriber/Policy Holder Name *

Subscriber Birth Date *

Relationship to Patient

Financial Policy

I authorize release of any information acquired in the course of treatment necessary to complete and file medical claims to my insurance company or Medicare on my behalf. I hereby acknowledge financial responsibility for costs of services rendered for me or for the person whose account for which I am acting as guarantor. I authorize (assign) any insurance or Medicare benefits to be paid directly to Med Psych Integrated or its assignees. I am responsible for any non-covered services, supplies, co-payments or deductible at the time of service. This acceptance and assignment will be in force for all future services by all practitioners from this office.

Signature *

Clear

Privacy Practices

SELF PAY PATIENTS

Patients who do not have insurance at the time of service will be considered self-pay. Payment for each visit must be made in full at each visit.

New Patient Evaluation: $300

Follow Up Appointments:

$150 for 20 min

$200 for 40 min

Signature *

Clear

Waiver of Electronic Mail Confidentiality Release

By providing my email address and cell phone and signing, I understand that I give Medpsych Integrated PLLC permission to e-mail me and or text me on the account given. Furthermore, I understand that e-mail/text is not a HIPAA compliant form of communication, nor is information protected in any way other than basic passwords. I waive any and all liability for Medpsych Integrated PLLC in the event of information disclosure that resulted from the use of e-mail.

Signature *

Clear

Lastly, you are invited to use Breeze, an electronic communication portal that is encrypted and HIPPA complaint. This will allow you to communicate with your provider, as well as see upcoming appointments, medications, and account details. Please ask the office for an invitation to be sent via email.

HIPAA Form

Right to access for friend, family member, or caregiver.

Would you like to add a friend, family member, or caregiver to allow them to communicate with the practice staff? ( if "YES" complete below, if "NO" skip and sign) *

Yes

I (Patient Name) direct my health care and medical services providers and payers to disclose and release my protected health information described below to:

Name *

Last Name *

Relationship to Patient *

Health Information to be disclosed upon the request of the person named above: (check only 1 option) *

Disclose my complete health record (including but not limited to diagnoses, lab tests,prognosis, treatment, and billing, for all conditions)

Disclose ONLY billing/financial information

Disclose ONLY medical information

Patient/Parent Signature *

Clear

Practice Policies

I (Patient Name) direct my health care and medical services providers and payers to disclose and release my protected health information described below to:

Thank you for choosing Medpsych Integrated PLLC for your psychiatric care. We are committed to providing the highest quality of treatment. Please read each policy below and enter your name here: *

Your name above serves as acknowledgement that you have read each policy.

INSURANCE Our providers are credentialed with several insurance providers. If we are not contracted with your insurance carrier, you are responsible for full Self Pay rate payment at the time of service. If you have a deductible, you are responsible for paying each visit in full at the contracted rate for your insurance carrier until you have met your deductible obligation with the carrier. If your insurance carrier requires a co-payment, this is to be paid at each visit. Please notify the office if you have a change in insurance coverage. Authorizations for your first visit are your responsibility. You are responsible for payment for services rendered regardless of any determination made by an insurance company.

1. It is my responsibility to inform the office of any insurance changes.

2. I agree to pay my copay or deductible at the time of service.

I (patient listed above), have reviewed the Policies and Procedures of Medpsych Integrated and understand and agree to these policies.

Signature *

Clear

Practice Policy on Patient Accounts

We do not carry patient balances. All fees are due at the time of service. A valid credit card or debit card is required by all patients. If there is an unpaid balance on your account any pending follow up appointments are subject to cancellation.

Patient Name

First Name *

Last Name *

Patient Birth Date *

Signature *

Clear

Raleigh Location:

7780 Brier Creek Parkway

Suite 306

Raleigh, NC 27617

Cary Location:

1110 SE Cary PKWY

Suite 207

Cary, NC 27518

Phone: 919-582-7272

Fax: 833-941-3156

Raleigh Location:

7780 Brier Creek Parkway

Suite 306

Raleigh, NC 27617

Cary Location:

1110 SE Cary PKWY

Suite 207

Cary, NC 27518

Phone: 919-582-7272

Fax: 833-941-3156

Psychiatrist in Raleigh - Medication Management - Psychiatric Evaluations - Accepting New Patients

The content on this website is for general information and educational purposes only, and is not intended to substitute professional services.