• MEDICAL HISTORY FORM

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  • MEDICAL HISTORY

  • PERSONAL HISTORY

  • FAMILY HISTORY

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  • EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT
  • SYSTEMS REVIEW

    In the past month, have you had any of the following problems?
  • WOMENS REPRODUCTIVE HISTORY
  • SUBSTANCE MISUSE

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  • PATIENT INFORMATION

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  • I hereby authorize Lott Behavioral Health, Ltd. to furnish my insurance company all information that may be requested concerning claim processing. I am financially responsible for charges not covered by my insurance company. I hereby assign to Lott Behavioral Health, Ltd. all monies to which I am entitled for expenses relative to the services received. I understand that if I am self-pay or have out-of-network insurance that payment is due in full at the time of service and my insurance company will need to reimburse me personally.

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  • Appointment Reminders

  • The office currently uses an automated system to send some appointment reminders. These reminders, whether through the automated system or otherwise, are given as a courtesy and do not affect the cancellation policy. The system currently offers reminders by email as well as one of the following 2 additional methods: texting or automated call reminders, but these options could change in the future. The current system requires email in order to work.

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  • Additional Information:
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  • I consent to receive emails, calls, or text messages from the practice at my phones and any number forwarded or transferred to/from that number or emails to receive communication as stated above. I understand that this request to receive emails, calls, and text messages will apply to all future appointment reminders unless I request a change in writing. The practice does not charge for this service, but standard data rates may apply as provided in my plans. I understand that although the systems use secure communication, no electronic communication can be completely secure from all unforeseen circumstances.

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  • MEDICATION LIST

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  • Should be Empty: