Scott R. Elkin, D.O., F.A P.A. Somatic Psychotherapies ... Scott R. Elkin, D.O., F.A P.A. Somatic...

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  • Scott R. Elkin, D.O., F.A P.A. Somatic Psychotherapies

    Katie J. Martin, PA-C Website: www.drelkin.com 3705 Medical Pkwy #450 Phone: 512-306-0061

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    Scott R. Elkin, DO, PA 3705 Medical Pkwy #450, Austin, TX 78705 512-306-0061

    PATIENT INFORMATION FORM PLEASE PRINT CLEARLY

    Patient Name: ___________________________________________________ DOB: _____________________

    Address: _________________________________________ City/State: ______________ Zip: _____________

    Home Phone: ___________________ Work Phone: ___________________ Cell Phone: __________________

    Social Security Number: __________________________________ TDL: _______________________________

    Gender: □ Male □ Female Marital Status: □ Single □ Married □ Life Partner □ Divorced □ Separated □ Widowed

    Student Status: □ Full-Time □ Part-Time □ Non-student School Name: __________________________________

    Email Address: _____________________________________________________________________________

    Preferred Contact Phone: __________________________________ □ Home □ Cell □ Work □ Other: ________

    Secondary Contact Phone: __________________________________ □ Home □ Cell □ Work □ Other: ________

    Emergency Contact: ____________________________________________________________

    Emergency Contact Phone: _________________________________ Relationship: ________________________

    Patient or Parent/Guardian Employer: ___________________________________________________________

    Position/Title: ________________________________________ Length of time in current position: __________

    Address: _________________________________________ City: ____________________ Zip: ____________

    Parent(s) / Guardian(s) Name (if patient is a minor): __________________________________________

    Address: _________________________________________ City: ____________________ Zip: ____________

    Home Phone: ________________________________________ O.K. to leave message? □ Yes □ No

    Work Phone: _________________________________________ O.K. to leave message? □ Yes □ No

    Cell Phone: __________________________________________ O.K. to leave message? □ Yes □ No

    If patient, is a minor, who is legally responsible for medical expenses? ________________________________

    Current Mental Health and/or Therapist Name: _____________________ Phone_____________ ok to call? Y N

    Previous Mental Health and/or Therapist Name: ____________________ Phone_____________ ok to call? Y N

    PCP: _______________________________________________ Phone: ________________________________

    Cardiologist: _________________________________________ Phone: ________________________________

    Neurologist: _________________________________________ Phone: ________________________________

    Pharmacy: ___________________________________________ Phone: _______________________________

    http://www.drelkin.com/

  • Scott R. Elkin, D.O., F.A P.A. Somatic Psychotherapies

    Katie J. Martin, PA-C Website: www.drelkin.com 3705 Medical Pkwy #450 Phone: 512-306-0061

    A u s t i n , T e x a s 7 8 7 0 5 F a x : 5 1 2 - 3 0 6 - 0 0 6 9

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    Scott R. Elkin, DO, PA 3705 Medical Pkwy #450, Austin, TX 78705 512-306-0061

    OFFICE POLICIES AND PROCEDURES

    Welcome to our office. Our purpose is to assist you in improving the quality of your life and that of your family through

    greater awareness, communication, and self-discipline. The following information is designed to begin that process.

    APPOINTMENTS: Initial evaluations are 60 to 120 minutes. Follow-up appointments are scheduled in accordance with your treatment plan. Please be on time so that you receive all of your scheduled time.

    FEES AND PAYMENTS: Our office will submit claims and accept insurance assignment/reimbursements from insurance carriers for which we are listed as in-network. You will be responsible for any coinsurance amounts, co-

    payments and deductibles as outlined by your insurance carrier. If we are not “in-network” with your insurance carrier,

    you will be responsible for payment in full at the time services are rendered. It is this office’s policy to file only primary

    insurance; secondary insurance will not be filed by our office. All private payments, copayments, coinsurance payments and deductibles are due at the time of each visit. Please provide all pertinent insurance carrier information

    at your initial visit and/or new insurance information as soon as possible. Failure to provide this information could result

    in patient responsibility of payment in full of the fees as listed above. An administration fee will be assessed for copies of medical records, letters written and forms completed on your behalf. We do not provide psychiatric assessments for

    legal cases. Subpoena fees are charged at a minimum of $2,500 per day.

    Our staff schedules follow up appointments according to your medication schedule. Should circumstances arise which

    prevent you from keeping your scheduled follow up appointment or if you fail to schedule your follow up appointment in

    a timely manner (before medications are due for renewal), we will schedule/reschedule your appointment for the next

    available opening. A $15.00 fee will be charged to refill medication between appointments. Our office does not refill

    medications on weekends or holidays. We require a 48-hour notice for prescription refills.

    If you must cancel your appointment, please call two business days in advance so your time can be made available to someone else. Patients who miss their appointment or do not provide two business days notification of cancellation,

    will be financially responsible for a missed appointment fee. Missed sessions cannot be billed to insurance companies and payment in full is due prior to the next appointment. It is difficult to provide effective continuity of care to patients who consistently miss and/or cancel their appointments. Patients who are unable to keep their scheduled

    appointments and/or consistently miss appointments will receive notification of discontinuation of services via postal

    service. We will provide 30 days of coverage from the date of the letter to allow time to seek another provider.

    Phone contact is encouraged; however, we must be conscientious of time management as to serve and address the needs

    of all patients. If you have an issue that may require more than 5 minutes, we recommend you schedule an appointment.

    A fee will be charged for telephone calls that exceed 5 minutes if they are directly related to patient care. Phone calls cannot be billed to insurance companies; you will be responsible for payment. *This does not include calls regarding

    scheduling or insurance matters. Phone fees: 15 minutes is $115, 30 minutes is $175, 45 minutes is $275 & 60 minutes is

    $350.

    By signing below, you acknowledge that you have read and understand the policies and procedures as set forth above.

    Additionally, you give authorization of payment of medical benefits to our office for services rendered. If you have any

    questions or concerns, please don’t hesitate to communicate with either Dr. Elkin or his office manager. We want to support you in taking care of yourself. The process begins right now. We appreciate the trust you have extended in

    allowing us to assist you.

    ________________________________________________ _____________________________________________

    Printed Name of Patient Patient/Guardian Signature Date

    ________________________________________________

    Printed Name of Parent / Guardian □ Self □ Parent □ Guardian

    http://www.drelkin.com/

  • Scott R. Elkin, D.O., F.A P.A. Somatic Psychotherapies

    Katie J. Martin, PA-C Website: www.drelkin.com 3705 Medical Pkwy #450 Phone: 512-306-0061

    A u s t i n , T e x a s 7 8 7 0 5 F a x : 5 1 2 - 3 0 6 - 0 0 6 9

    3

    Scott R. Elkin, DO, PA 3705 Medical Pkwy #450, Austin, TX 78705 512-306-0061

    OFFICE POLICIES AND PROCEDURES

    The following information summarizes our Office Policies and Procedures contained in the New Patient Paperwork you

    completed and signed in our office. Please read it carefully. If you have any questions or concerns, please do not hesitate to communicate with either Dr. Elkin or his office staff.

    FEES AND PAYMENTS:

     All private payments, copayments, deductibles and coinsurance are due at the time of each visit.  Our office only submits claims to insurance companies for which we are “in-network”. Secondary insurance is

    not filed.

     Failure to provide current insurance information could result in patient responsibility of payment in full of the fees as listed above.

    MEDICATION REFILLS:  Appointments are scheduled prior to patient prescriptions running out.  There is a $15.00 prescription refill fee for refilling prescriptions between appointments.  We require a 48-hour notice for prescription refills.

     Our office does not refill medications on weekends or holidays.

    APPOINTMENTS:

     Courtesy appointment reminders are made two business days in advance of your appointmen