New Patients: Request Appointment

Choose a Provider*

No preference - Best scheduling & insurance matchBill Hart, LCSWDonna Hammond, LCSWSandra F. Allen, Ph.D. (*NOT taking new patients at this time*)

D. Hammond & Associates offers appointments through telehealth (video chat) and I understand that I will not be receiving in-person appointments.*

Yes, I agree

See which providers accept your insurance here.

Care needed*

Patient's Name*

First NameLast Name

Patient's Preferred Name

Patient's Date of Birth*

Date

Patient's Age*

Best Phone Contact*

Area CodePhone Number

Email*

example@example.com

Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient's Social Security Number*

Patient's Sex*

Patient's Gender Identity

Patient's Marital Status*

Emergency Contact Name*

Emergency Contact Relation*

Emergency Contact Phone Number*

Referral Source

Insurance Provider*

Are you using EAP benefits?*

Name of Policy Holder*

First NameLast Name

Relationship of Policy Holder to Patient*

Policy Holder's Date of Birth*

Date

Policy Holder's Social Security Number*

Policy Holder's Address*

Group Number*

ID #*

Insurance Company's Phone Number for Provider Verification (Check the back of your insurance card)*

Area CodePhone Number

Upload a photo(s) of your insurance card, front & back or other insurance documents so we can verify coverage before your first appointment.

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Responsible Party for Billing *(if different than insured party)*

Responsible Party Mailing Address

Responsible Party Social Security Number

Current Medications*

Previous Diagnosis*

Does The Patient Require Disability/FMLA Paperwork Completed?*

Please note: Our psychiatrists only complete paperwork for established (3 months) patients.

Reason for Appointment*

If the patient is a minor, complete the following information.

Patient's Legal Guardian

First NameLast Name

Relation of Legal Guardian to Patient

School Name

If Applicable

School Phone Number

Current Legal Issues And/Or Custody Disputes

Financial Policy:

I understand that I am personally responsible for the payment of any and all charges accrued during the provision of services provided to me by the above listed providers at D. Hammond & Associates. If I have private insurance and/or Medicaid I understand that it is my responsibility to verify my benefits being deemed “subject to change.” I also understand that verifications of benefits does not guarantee payment to the physician or clinic. I agree to pay for any outstanding balance not covered by my private insurance(s) which includes: deductibles, copayments, non-authorized services, and non-billable services. If I cannot pay my balance within a reasonable time frame, I authorize the release of information that pertains to the outstanding balance to a collections account. I understand that a fee schedule that outlines the clinic charges for services is available to me upon request.

We are not able to guarantee specific insurance coverage and recommend reaching out to your insurance provider to inquire about coverage, co-pays, and deductibles.

Cancellation/Termination Policy:

I understand that it is my responsibility to show up for my scheduled appointment(s).I understand that I must give a 24-hour notice to the clinic if I need to cancel my appointment. Failure to give sufficient notice of cancellation will constitute as a “no show” and you will be billed a “$50.00 NO SHOW CHARGE” to your account. This fee must be paid prior to receiving additional services. This fee cannot be billed to Medicaid and/or private insurances. I understand that I am only allotted 3 consecutive “no shows,” and will be terminated. I understand that I am only allotted 4 “no shows” in a 4 month time period, and will be terminated if I have 4 “no shows” in 4 months.

Consent to Treat:

1. I give permission for D. Hammond & Associates to give me medical treatment.

2. I allow D. Hammond & Associates to file for insurance benefits to pay for the care I receive. I understand that:
- D. Hammond & Associates will have to send my medical record information to my insurance company.
- I must pay my share of the costs.
- I must pay for the cost of these services if my insurance does not pay or I do not have insurance.

3. I understand:
- I have the right to refuse any procedure or treatment.
- I have the right to discuss all medical treatments with my provider.

Patient Name*

First NameLast Name

Responsible Party*

First NameLast Name

Signature*

New Patient Request