Download - Scott R. Elkin, D.O., F.A P.A. Somatic Psychotherapies ...Scott R. Elkin, D.O., F.A P.A. Somatic Psychotherapies Katie J. Martin, PA-C Website: 3705 Medical Pkwy #450 Phone: 512-306-0061

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/




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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





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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 appointment. Patients arriving 10 minutes after your scheduled appointment time are subject to being rescheduled.

Appointments must be cancelled 48 business hours in advance to avoid a missed appointment charge.

Cancellations made less than 48 business hours prior to your appointment and missed appointments will incur a missed appointment fee: $200 for missed appointment with notification and $125 for missed appointments for

same day cancellation..

Missed appointment fees must be paid prior to the next appointment.

Patients who are consistently unable to keep their scheduled appointments will receive notification of discontinuation of services via postal service.

Patients will be billed for phone calls that directly relate to patient care that exceed 5 minutes.

Phone visit are not covered by insurance and will be patient’s responsibility & will be charged on time spent: 15 minutes is $115, 30 minutes is $175, 45 minutes is $275 & 60 minutes is $350.

MISCELLANEOUS:

Medical Records Requests (not related to SSI determination)

□ Administration fees for copies of medical records are charged as follows:

Pages 1 – 20: $25.00, $0.50 per page over 25 pages plus postage.

Letters/Forms

□ Letters written and forms completed on your behalf are charged at $50 each.

Disability and/or Legal Paperwork

□ An appointment must be scheduled for the completion of Long Term or Short Term Disability Forms.

□ We do not provide psychiatric assessments for legal cases. Subpoenas are charged at a minimum of $2,500 per day.

HOURS OF OPERATION:

Office Hours: Monday through Friday 8:30 am – 5:00 pm Appointments available: Monday through Friday 9:00 am – 5:00 pm. (Some after hour appointments are available)

Telephone Hours: Monday through Friday 9:00am – 12:00pm and 1:00 pm – 4:00pm

Please feel free to utilize our website at www.drelkin.com.






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Acknowledgement of Receipt of Notice of Privacy Practices

________________________________________ ________________________________________________ Printed Name of Patient Printed Name of Parent / Guardian

___________________________________________ Relationship to Patient: ___________________________

Patient OR Parent / Guardian Signature □ Self □ Parent □ Guardian

For Our Office Use Only

Our office attempted to obtain written acknowledgement of receipt of our Notice of Privacy

Practices, but acknowledgement could not be obtained for the following reason:

□ Patient refused to sign acknowledgment.

□ Communication barriers prohibited obtaining the acknowledgement.

□ An emergency situation prevented us from obtaining acknowledgement

□ Other (describe below):

________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________

***Employee must sign and date***

________________________________________ Printed Employee Name

______________________________________ _________________________

Signature of Employee Date





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INSURANCE INFORMATION

(Please present card for copying)

Insurance Company Name: ________________________________________ □ HMO □PPO □POS

Insurance Company Phone Number: __________________________________________________________________

Policy Holder Name: ________________________________________ SSN: __________________________________

Policy / Member Number: _________________________________ Group #:______________________________

Employer’s Name: ___________________________________ Phone: ___________________________________

Patient / Parent / Guardian Signature Date

________ Copy of the current insurance identification card obtained.

________ I understand that Dr. Elkin’s office does not have a copy of the current insurance identification

card(s) for ________________________. If I do not provide the office with a copy of the card in sufficient

time for the office to file the claim within the insurance carrier’s filing deadline, I agree to be responsible for

payment in full of charges for services rendered.

________ I understand that Dr. Elkin is accepting _______________________ as a private pay patient

for the period of time during which insurance is not effective or as strictly a private pay patient. I will be

responsible for payment for services rendered during that period of time.

_______________________________ _______________________________

Printed Name of Patient Printed Name of Parent / Guardian

_______________________________ _______________________________

Patient OR Parent / Guardian Signature Date

Relationship to Patient: □ Self □ Parent □ Guardian

_______________________________

Office Employee Witness Signature

PATIENT CONSENT FORM





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I understand that I have certain rights to privacy regarding my protected health information. These rights are

given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand that

by signing this consent I authorize you to use and disclose my protected health information to carry out:

Treatment (including direct or indirect treatment by other healthcare providers involved in my

treatment);

Obtaining payment from third party payers (e.g. my insurance company);

The day-to-day healthcare operations of your practice. Including calling to remind me of my

appointment or at my request (either written or verbal), to fax information to a school or place of

employment, that I (or my child) missed school or work due to a medical appointment.

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy

Practices, which contains a more complete description of the uses and disclosures of my protected health

information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this

notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I, the patient, understand that I have the right to request restrictions on how my protected health information is

used and disclosed to carry out treatment, payment, and health care operations, but that you, the physician, are

not required to agree to these restrictions. However, if you, the physician, do agree, you are then bound to

comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use of disclosure that

occurred prior to the date I revoked this consent is not affected.

Signed on the _______________ day of _______________, 20_________.

____________________________________ ____________________________________

Printed Name of Patient Printed Name of Parent / Guardian

____________________________________ Relationship to Patient: _________________

Patient OR Parent / Guardian Signature □ Self □ Parent □ Guardian





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Patient Name: ____________________________________ Date: __________________________________

INSTRUCTIONS: The symptoms of anxiety can be divided into those effecting feelings, thoughts, and the body. To find out the level of your anxiety, put a check (√) in the space to the right that best describes how much that symptom or problem has bothered you during the past week. Category I: Anxious Feelings

Not at all 0

Somewhat 1

Moderate 2

A lot 3

1. Anxiety, nervousness, worry or fear.

2. Feeling that things around you are strange, unreal or foggy.

3. Feeling detached from all or part of your body.

4. Sudden, unexpected panic spells.

5. Apprehension or a sense of impending doom.

6. Feeling tense, stressed, “uptight” or on edge.

Category II: Anxious Thoughts

Not at all 0

Somewhat 1

Moderate 2

A lot 3

7. Difficulty concentrating.

8. Racing thoughts or having your mind jump from one thing to the next.

9. Frightening fantasies or daydreams.

10. Feeling that you’re on the verge of losing control.

11. Fears of cracking up or going crazy.

12. Fears of fainting or passing out.

13. Fears of physical illness or heart attacks or dying.

14. Concerns about looking foolish or inadequate in front of others.

15. Fears of being alone, isolated, or abandoned.

16. Fears of criticism or disapproval.

17. Fears that something terrible is about to happen.





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Category III: Physical Symptoms

Not at all 0

Somewhat 1

Moderate 2

A lot 3

18. Skipping, racing or pounding of the heart (sometimes called palpitations).

19. Pain, pressure or tightness in the chest.

20. Tingling or numbness in the toes or fingers.

21. Butterflies or discomfort in the stomach.

22. Constipation or diarrhea. Category III: Physical Symptoms, cont.

Not at all 0

Somewhat 1

Moderate 2

A lot 3

23. Restlessness or jumpiness.

24. Tight, tense muscles.

25. Sweating not brought on by heat.

26. A lump in the throat.

27. Trembling or shaking.

28. Rubbery or “jelly” legs.

29. Feeling dizzy, light-headed or off balance.

30. Choking or smothering sensations or difficulty breathing.

31. Headaches or pains in the neck or back.

32. Hot flashes or cold chills.

33. Feeling tired, weak, or easily exhausted.

Interpreting your anxiety score: 0 – 5: Minimal 6 – 15: Mild 16 – 30: Moderate 31 – 50: Severe Over 50: Extreme Copyright 1984 David D. Burns, M.D.





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THE MOOD DISORDER QUESTIONNAIRE

Instructions: Please answer each question as best you can. Upon completing this form, you will be able to

print your completed form and take it to your health care practitioner.

1. Has there ever been a period of time when you were not your usual self and…

...you felt so good or hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? O YES O NO

…you were so irritable that you shouted at people or started fights or arguments? O YES O NO

…you felt much more self-confident than usual? O YES O NO

…you got much less sleep than usual and found you didn’t really miss it? O YES O NO

…you were much more talkative or spoke much faster than usual: O YES O NO

…thoughts raced through your head or you couldn’t slow your mind down? O YES O NO

…you were so easily distracted by things around you that you had trouble concentrating or staying on track? O YES O NO

…you had much more energy than usual? O YES O NO

…you were much more active or did many more things than usual? O YES O NO

…you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? O YES O NO

…you were much more interested in sex than usual? O YES O NO

…you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? O YES O NO

…spending money got you or your family into trouble? O YES O NO

2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? O YES O NO

3. How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; getting into arguments or fights? Please select one response only.

O No problem O Minor Problem O Moderate Problem O Serious Problem

MEDICAL HISTORY FORM





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Patient Name: ___________________________________ DOB: __________________________________

Current Weight_________ Current Height _________

Please check if you have been diagnosed with any of the conditions listed below:

High blood pressure __________ Seizures __________ Asthma __________

High Cholesterol __________ Head Injury __________ Cancer __________

Heart Disease __________ Migraine __________ Liver Disease __________

Diabetes __________ Glaucoma __________ Kidney Disease __________

Thyroid Problems __________ Chronic Pain __________ Sleep Apnea __________

________________

________________

Other Serious Illness:________________________________________________________________________________ ________________

List any past hospitalizations and their dates including psychiatric hospitalizations and substance abuse

treatment:______________________________________________________________________________________

________________

_______________________________________________________________________________________________

________________

_______________________________________________________________________________________________

Please list any psychiatric conditions you have been diagnosed with in the past. ______________________________

______________________________________________________________________________________________

Are you currently under medical care for any reasons? If yes, please explain: ________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________

List the medications, herbs, and nutritional supplements you are now taking:

______________________________________________________________________________________________

______________________________________________________________________________________________

List any allergies you have to medication:____________________________________________________________

Primary Care Physician: _______________________ Phone: ____________________ Fax: ___________________

Current Psychotherapist: ______________________ Phone: ____________________ Fax: __________________

Past Psychiatric Provider:______________________ Phone: ____________________ Fax: __________________

WOMEN ONLY:

Please check what best describes you: I am pregnant I have regular menstrual periods

I am perimenopausal I am menopausal I had a hysterectomy

Do you experience variations in mood or anxiety level related to your menstrual period? yes no

Signature_______________________ Date___________________





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Over the last 2 weeks, how often have you been bothered by any of the following problems?

Circle your answer Not at

all

Several days

More than

half the days

Nearly every day

1. Little interest or pleasure in doing things 0

1 2 3

2. Feeling down, depressed, or hopeless 0

1 2 3

3. Trouble falling or staying asleep, or sleeping too much 0

1 2 3

4. Feeling tired or having little energy 0

1 2 3

5. Poor appetite or overeating 0

1 2 3

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0

1 2 3

7. Trouble concentrating on things, such as reading the newspaper or watching television 0

1 2 3

8. 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 0

1 2 3

9. Thoughts that you would be better off dead or of hurting yourself in some way 0

1 2 3

FOR OFFICE CODING 0 + ______ + ______ + ______

Total Score: ____________

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 along with other people? Not

difficult

Somewhat

Very

Extremely

at all

difficult

difficult

difficult

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.





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Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist

Please answer the questions below, rating yourself on each of the criteria shown

using the scale on the right side of the page. As you answer each question, place an

X in the box that best describes how you have felt and conducted yourself over the

past 6 months. Please give this completed checklist to your healthcare professional to

discuss during today’s appointment.

Part A

Never

Rare

ly

So

meti

mes

Oft

en

Very

Oft

en

1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done?

2. How often do you have difficulty getting things in order when you have to do a task that requires organization?

3. How often do you have problems remembering appointments or obligations?

4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started?

5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time?

6. How often do you feel overly active and compelled to do things, like you were driven by a motor?

Part B

7. How often do you make careless mistakes when you have to work on a boring or difficult project?

8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work?

9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?

10. How often do you misplace or have difficulty finding things at home or at work?

11. How often are you distracted by activity or noise around you?

12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated?

13. How often do you feel restless or fidgety?

14. How often do you have difficulty unwinding and relaxing when you have time to yourself?

15. How often do you find yourself talking too much when you are in social

situations?

16. When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?

17. How often do you have difficulty waiting your turn in situations when turn taking is required?

18. How often do you interrupt others when they are busy?


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Scott R. Elkin, D.O., F.A P.A.Somatic Psychotherapies Katie J. Martin, PA-CWebsite: www.drelkin.com 3705 Medical Pkwy #450Phone: 512-306-0061 Austin, Texas 78705Fax: 512-306-0069

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