New Patient Intake Forms

SUMMIT BEHAVIORAL HEALTH

PHONE: 651-358-7020 FAX: 612-293-6742
NEW PATIENT INTAKE FORM
Please Note:
1. Our providers don’t prescribe certain medications such as CLOZAPINE and LONG ACTING INJECTABLES.
2. Providers use clinical judgement along with thorough evaluation, neuropsychological testing and review of past medical records to determine the need for prescribing controlled substances such as STIMULANTS, BENZODIAZEPINES, and SEDATIVE-HYPNOTICS.
3. Establishing an appointment does not guarantee prescription of certain medications you may already be taking .
Date *

Month Day Year
Date
Which services are you looking for?
Would you like to meet a provider in-person or through video call?
Our providers can only treat Minnesota residents. Are you a Minnesota resident and currently located in the state of Minnesota? *
We don't have language interpretation services at our clinic. Would you need interpretation services for your appointment with provider? *
Please click " Browse Files" button below to take a picture of your photo ID and Insurance card and upload files. It is important for us to have a copy of your ID and Insurance in order to confirm your appointment and for processing claims. Call us on 651-358-7020 if you are unable to upload these documents.
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Name *

First Name Last Name
Date of Birth *
Age (our providers treat patients from 18-62 years of age) *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mobile Phone Number *

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Email
example@example.com
Gender
Marital Status *
Race *
Ethnicity *
Patient Employer Information
Employment Status *
Employer Name
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contacts
Name *
Phone Number *

Area Code Phone Number
Relationship *
Name
Phone Number

Area Code Phone Number
Relationship
Patient Insurance Information
* Enter N/A if you are self/cash pay patient
Insurance Company Name: (Primary) *
ID# *
Group#
Policy Holder's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Policy Holder's Name *
Policy Holder's Date of Birth *

Month Day Year
Date
Insurance Company Name: (Secondary)
* Enter N/A if you are self/cash pay patient
ID#
Group#
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Policy Holder's Name
Policy Holder's Date of Birth
PREFERRED PHARMACY FOR YOUR PRESCRIPTIONS (IF APPLICABLE)
WHERE DID YOU FIRST HEAR ABOUT SUMMIT BEHAVIORAL HEALTH?

General Consent for Care and Treatment Consent
TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

I voluntarily request a physician, and/or mid level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
Signature of Patient or Personal Representative *

Clear
Date *

Month Day Year
Date
Printed Name of Patient or Personal Representative: *
Relationship to Patient

FINANCIAL DISCLOSURE
Summit Behavioral Health may not contract with all commercial insurance carriers and may be an "out of network" provider for some insurance carriers and health benefit plans. Please check with your carrier or benefit plan because your out-of -network payment responsibility may be higher than an in-network option. The undersigned agrees, whether she/he signs as agent or a patient, that in consideration of the services to be rendered to patient, she/he hereby is responsible for paying copayments, deductibles, coinsurance amounts, and any balance deemed to be a covered benefit of the insurance policy. Acceptable means of payment are cash, money order, cashiers check, credit card, or personal check.

If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

Claims submission: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

Co-payments and deductibles: All co-payments and deductibles must be paid at the time of service or soon after your visit. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.

Coverage changes: If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. I f your insurance company does not pay your claim in 60-90 days, the balance will automatically be billed to you.

Nonpayment: If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our provider will only be able to treat you on an emergency basis.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

ASSIGNMENT OF INSURANCE BENEFITS & AUTHORIZATON TO RELEASE INFORMATION Summit Behavioral health may not contract with all commercial insurance carriers, and may be an "out of network" provider. I understand that Summit Behavioral health will verify my benefits, collect a portion of my responsibility (i.e. co-pay, deductible and/or co-insurance) at the time of service and bill my insurance provider for the services benefits. I further understand that if any of the services or charges are not covered by my insurance company/benefit plan or Summit Behavioral health is unable to verify eligibility, I am responsible for all charges incurred for services rendered. I hereby assign and transfer to Summit Behavioral health all right, title, and interest in any and all health insurance and/or health plan proceeds/benefits from any of my plans(s) arising from the provision of any goods and services provided by Summit Behavioral health and/or any physicians/healthcare providers thereof. I also hereby assign and transfer to Summit Behavioral health all right, title and interest in any claims against any health insurers, sponsors and/or plan administrators of any of my health benefit plan(s) arising from or pertaining to any wrongful acts and/or omissions pertaining to any of said health/benefit plan(s) or health insurance policy(ies), including but not limited to claims for the non-payment or underpayment of health provider invoices and claims. I further expressly and knowingly assign all rights under my benefit plan the Employee Retirement income Security Act of 1974 to sue my benefit plan for any breach of its fiduciary duty. By executing this assignment of .benefits, I am directing the health insurance carrier or other health benefit plan providing my coverage (including, but not limited to, any employer, employer group, or trust sponsored or offered plan) to pay the Facility and/or Facility-based providers. Summit Behavioral health files primary and secondary insurance claims for insured patients. I authorize the facility and/or providers indicated above to release medical information about me as may be necessary for the completion of my insurance claims for this occasion of service to any insurance carrier, health or hospital plan.

MEDICARE PAYMENTS: (Patient's Certification, Authorization to Release Information, and Payment Request) I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf.

OUT OF STATE MEDICAID: Summit Behavioral health is not enrolled with any out of state Medicaid plans. By signing this form, I acknowledge that I will be responsible for charges if reimbursement is not available through my Medicaid provider.

The undersigned certifies that she/he is the patient or is duly authorized by the patient as the patient's general agent to execute the above and accepts its terms.
Signature of Patient or Personal Representative *

Clear
Date *

Month Day Year
Date

MEDICAL APPOINTMENT CANCELLATION/NO SHOW POLICY
Thank you for trusting your medical care to Summit Behavioral Health. When you schedule an appointment with us, we set aside enough time to provide you with the highest quality care. Should you need to cancel or reschedule an appointment please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointment. Please see our Appointment Cancellation/No Show Policy below:
 Effective Aug 19, 2019 any patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours notice will be considered a No Show.

 If a third No Show or cancellation/reschedule with no 24 hour notice should occur the patient may be discharged from Summit Behavioral Health.

 As a courtesy, when time allows, we make reminder calls for appointments and/or send automated text reminders. If you do not receive a reminder call or message, the above Policy will remain in effect.
We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances please contact our Office Manager. You may contact us on 651-358-7020 24 hours a day, 7 days a week. Should it be after regular business hours Monday through Friday, or a weekend, you may leave a message.
I have read and understand the Medical Appointment Cancellation/No Show Policy and agree to its terms.
Signature *

Clear
Date *

Month Day Year
Date

CREDIT CARD CONSENT FORM
Name on card if different

First Name Last Name
In order to ensure timely payment for services provided, we ask that you provide us with a credit/debit card to put on file for any balances on your account. By signing this form, you are authorizing Summit Behavioral Health to charge this card for professional services as follows:

• Any co-pays, deductibles, co-insurance, or spend-down amounts due

• Any remaining balances after insurance is billed (please note not all plans have a balance after insurance is billed)

• The entire session fee if no insurance policy is being billed

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me

• That I fully understand its contents

• That I have been given ample opportunity to ask questions and that any

questions have been answered to my satisfaction.
BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD
AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Signature

Clear
Date

Month Day Year
Date
CREDIT CARD NUMBER

Street Address Line 2

csc ( 3 OR 4 digit security code) Expiration Date

Billing Zipcode

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

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

	Selection
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
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
9. Thoughts that you would be better off dead, or of hurting yourself

Add Each Row Score Above And Input Total Below
If you check 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 at all Somewhat difficult Very difficult Extremely difficult

EPWORTH SLEEPINESS SCALE

How likely are you to doze off or fall asleep in the following situations? In contrast to just feeling tired, this refers to your usual way of life in recent times . Even if you have not done some of these things recently try to think through how you might have felt in each setting. Use the following scale to choose the most appropriate number for each situation: *

	Selection
Sitting and reading
Watching TV
Sitting inactive in a public place
Being a passenger in a motor vehicle for
an hour or more
Lying down in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (no alcohol)
Stopped for a few minutes in traffic
While driving

Add Each Row Score Above And Input Total Below

	YES	Dosage	Dates prescribed	Response/side effect
Prozac/fluoxetine
Zoloft/sertraline
Luvox/fluvoxamine
Paxil/paroxetine
Celexa/citalopram
Lexapro/escitalopram
Effexor/venlafaxine
Cymbalta/duloxetine
Wellbutrin/bupropion
Remeron/mirtazapine
Serzone/nefazodone
Anafranil/clomipramine
Pamelor/nortptyline
Tofranil/imipramine
Elavil/amitriptyline
Tegretol/carbamazepine
Lithium
Depakote
Lamictal/lamotrigine
Tegretol/carbamazepine
Topamax/topiramate
Seroquel/quetiapine
Zyprexa/olanzepine
Geodon/ziprasidone
Abilify/aripirprazole
Clozril/clozapine
Haldol/haloperidol
Prolixin/fluphenazine
Risperdal/risperidone
Ambien/zolpidem
Sonata/zaleplon
Rozerem/ramelton
Restoril/temazepam
Desyrel/Trazadone
Adderall/amphetamine
Concerta/methylphenidate
Ritalin/methylphenidate
Strattera/atomoxetine
Xanax/alprazolam
Ativan/lorazepam
Klonopin/clonazepam
Valium/diazepam
Tranxene/clorazepate
Buspar/buspirone

	Yes/No	Full Name	Phone Number
Spouse
Child
Parent
Other
I don't wish to disclose

SUMMIT BEHAVIORAL HEALTH

Patient Employer Information

Emergency Contacts

Patient Insurance Information

General Consent for Care and Treatment Consent

FINANCIAL DISCLOSURE

MEDICAL APPOINTMENT CANCELLATION/NO SHOW POLICY

CREDIT CARD CONSENT FORM

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

EPWORTH SLEEPINESS SCALE

SUMMIT BEHAVIORAL HEALTH

LEGAL HISTORY

SUBSTANCE USE HISTORY

PAST PSYCHIATRIC HISTORY

Past Psychiatric Medication Trials

MEDICAL SYMPTOMS

LOW THYROID QUESTIONNAIRE

PATIENTS PROTECTED HEALTH INFORMATION PREFERENCES

SUMMIT BEHAVIORAL HEALTH

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

	Cause or Medication	Type of Reaction
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8
9

	DIAGNOSIS	DATE OF DIAGNOSIS
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