Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints to benefit you as well as help our practice operate efficiently. Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays. Medications Please bring ALL medications and supplements in the bottle or a current medication list with you to all office appointments. New Patient Registration New patients must arrive 20 mins early to register unless otherwise instructed. Please bring photo ID and insurance cards. We also have a Health History packet that we ask you to complete before coming into the office. Completing and bringing these forms along with your insurance cards will save you time in the office and make your waiting time as short as possible. Billing and Insurance If your insurance plan has a co-pay please be prepared to pay at the time of service each visit. We ask that you always make our receptionists aware of changes in address, phone numbers, and insurance as you sign in. Phone Calls We want to be responsive to your needs. If you need to speak with a physician or their MA please call during office hours unless you have an emergency then you can page the physician on call. Our phone hours are Monday through Friday from 7:30am-11:30am and 1:30pm-4:30pm. Prescription Refills Please ask your physician or nurse for all of your prescription refills at the time of your visit. This will ensure you have all of your needed medications. If you are needing a refill before your scheduled visit we ask that you contact the pharmacy and ask them to fax us a refill request to 423-643-2030. Any faxed refill request that is received by 4:30pm will be handled that same day. Lab Results and Test Results If you have lab work or test results pending, it is not necessary for you to call our office unless you have been instructed to do so by your physician. A medical assistant will call you with the results after they are reviewed by your physician. If you have any questions about any part of the registration process, or anything pertaining to your appointment, please feel free to call us. We are here to serve you. Sincerely, CHI Memorial Integrative Medicine Associates 320 E Main ST Suite 200 Chattanooga, TN 37323 *PH: 423-643-2246 *Fax: 423-643-2030
CHI MEMORIAL INTEGRATIVE MEDICINE ASSOCIATES FINANCIAL POLICY It is our objective to provide you with the highest quality healthcare in the most cost effective manner. If you have medical insurance we will be happy to file the claim form on your behalf. We do this as a courtesy to our patients to help you receive the maximum allowable benefits from your insurer. We need to be actively involved in the insurance claims process to insure accuracy and effectiveness. Commercial Insurance Patients Please remember that your insurance contract is between you and your insurer. If you insurance company pays only part of your bill or rejects your claim you are financially responsible for the balance. Commercial insurance carriers should be prepared to pay a minimum of 20% of their bill at the time of service. Patients with no insurance Patient s that do not have insurance are asked to pay for their visit at the time of service. We will be glad to set up payment arrangements if that is necessary. If you have any questions, please do not hesitate to ask us. We are here to help you. We accept payments in the form of cash, check, and most types of major credit cards. Patient Signature Date
Individual Notice of Privacy Practices Acknowledgement I acknowledge that I received a copy of CHI/Memorial Health Partners Foundation Notice of Privacy Practices (v03/2016) for (print patient s name). Signature of Patient Patient s DOB OR Signature of Patient Representative or Parent/Legal Guardian if Under 18 Individual (or patient representative/parent/legal guardian) did not sign the acknowledgement for the following reason (check below): Individual refused Individual refused, stating that he/she has already signed an acknowledgement There was not a personal representative of the individual available to sign Other (please explain): Signature of Witness Date Personal Representative of Patient As a patient you may designate one or more personal representatives. A personal representative may receive protected health information (PHI) about you. PHI includes medical conditions and diagnosis, treatment and prognosis, and billing and payments. You can remove or add personal representatives at any time. I (Patient) do not wish to designate a personal representative. I (Patient) designate the following personal representative(s): Name of Personal Representative Relationship Phone Name of Personal Representative Relationship Phone Consent for Telephone Communication I consent to receive telephone calls from Memorial Health Partners Foundation (MHPF) or a designated third party relating to my healthcare and other services. I agree to receive telephone calls at either my home telephone or my cellular telephone. I agree to allow MHPF to call my home or cellular telephone for purposes related to my care, to provide information about service offerings provided by MHPF, or for quality related surveys or communications related to my care. I understand that calls may be either live in-person calls or automated prerecorded communications. I understand that cellular service charges may apply. I understand that my consent to receive telephone calls is not a condition of my treatment. Home Phone Mobile Phone Signature of Witness Date
CHI Memorial Integrative Medicine Associates 1. Cancellation/ No Show Policy for Doctor Appointment We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, failing to call to cancel an appointment, may be preventing another patient from getting much needed treatment. As of July 1, 2016 if an appointment is not cancelled at least 24 hours in advance you will be charged a fifty dollar ($50) fee; this will not be covered by your insurance company. Three No-Show appointments will subject you to possible dismissal from the practice. 2. Scheduled Appointments We understand that delays can happen however we must try to keep the other patients and doctors on time. If a patient is 15 minutes past their scheduled time for a primary care visit or 10 mins for nutritional counseling and/or shows up after their appointment time without the required paperwork we will have to reschedule the appointment to a later time or date. // Print Name Patient Signature Patient/Guardian Date
Counseling Intake Form 320 E Main ST * Suite 200 * Chattanooga, TN 37408 Tel: (423) 643-2246 * FAX: (423) 643-2030 Client's name: Primary reason(s) for seeking services today: Date: Please check behaviors and symptoms that occur more often than you would like them to: Aggression Fatigue Panic Attacks Alcohol dependence Flashbacks Phobias/Fears Anger Grief Poor judgment Anxiety Hallucinations Self-Esteem Problems Chronic Pain Heart palpitations Sexual Difficulties Compulsive behavior High blood pressure Sleep problems Concentration Problems Hopelessness Social Withdrawal Cyber addiction Hyperactivity Suicidal thoughts Depression Impulsivity Thoughts disorganized Disorientation Irritability Trembling Distractibility Loneliness Unresolved Trauma Dizziness Memory impairment Worrying Drug dependence Mood swings Other (specify): Eating disorder Obsessive Thoughts Marital Status/Current Living Situation Single Married Living with significant Other Separated Divorced Widowed Assessment of current relationship (if applicable): Good Fair Poor Living? Living with you? Relationship Name Age Yes No Yes No Spouse/Partner Children Please check employment status: Employment employed full-time employed part-time unemployed disabled retired If currently employed, please list job information below: Employer Job Title How long there?
THIS FORM IS CONFIDENTIAL AND NOT AUTHORIZED FOR RE-RELEASE Counseling/Prior Treatment History Have you had any prior professional counseling or psychiatric treatment? Yes No If yes, please list most recent treatment episodes, who treated you, and outcome below: Approximate Treatment Dates Treatment Provider/Facility Outcome Medication and Chemical Use History Current Prescribed Medications Dose Frequency Purpose Side effects Have you ever been treated for alcohol or drug dependence/abuse? Yes No Have you ever felt like you should cut down on alcohol or other drug use? Yes No Has a friend or relative ever discussed concerns about your drug use? Yes No Have you ever felt guilty about your drinking or drug use? Yes No Have you had withdrawal symptoms when trying to stop using drugs or alcohol? Yes No Is there a history of problems with alcohol or drug use in your family? Yes No Please note any current or past use of the following substances: Amount Frequency Age of Age of Used in last Used in last of use First Use Last Use 48 hours? 30 days? Yes No Yes No Caffeine Nicotine Alcohol Marijuana Opioids/Narcotics Amphetamines Cocaine/Crack Inhalants LSD/Shrooms/PCP Other drugs
THIS FORM IS CONFIDENTIAL AND NOT AUTHORIZED FOR RE-RELEASE List any current health concerns: Medical/Physical Health Primary Care Physician's Name and Phone Number: Last physical exam Last doctor s visit Date Reason Results Family History/Development List any pertinent family history of medical, mental health, or substance abuse problems: Significant Family Members (e.g., parents, siblings, step-relatives, half-relatives.) Living? Living with you? Relationship Name Age Yes No Yes No Are there unusual or traumatic circumstances that affected your development? Yes No If Yes, please describe: Have you ever been a victim of sexual, physical, emotional, or verbal abuse? Yes No Fill in all that apply: High school grad/ged Education Vocational: Number of years: Graduated: Yes No Major: College: Number of years: Graduated: Yes No Major: Graduate: Number of years: Graduated: Yes No Major: Other training: Currently enrolled in school? Yes No (If yes, where? ) Special circumstances (e.g., learning disabilities, gifted): Social Relationships Check how you generally get along with other people: (check all that apply) Affectionate Aggressive Avoidant Fight/argue often Follower Friendly Leader Outgoing Shy/withdrawn Submissive Other (specify):
THIS FORM IS CONFIDENTIAL AND NOT AUTHORIZED FOR RE-RELEASE Spiritual/Religious How important to you are spiritual matters? Not Little Moderate Much Are you affiliated with a spiritual or religious group? Yes No If Yes, describe: Would you like your spiritual/religious beliefs incorporated into the counseling? Yes No If Yes, describe: Military Military experience? Yes No Combat experience? Yes No Where: Branch: Discharge date: Date enlisted: Type of discharge: Legal Current Status Are you involved in any active cases (civil, criminal)? Yes If Yes, please describe and indicate the court and hearing/trial dates and charges: No Any additional information that would assist us in understanding your concerns or problems: What are your goals for therapy? For Staff Use Therapist s signature/credentials: Date: / / Additional Comments/Information pertinent to treatment: