NEW PATIENT CONTACT INFORMATION

NEW PATIENT CONTACT INFORMATION
If you have a life threatening emergency please dial 911 or go to the nearest emergency room.

We understand that some patients would like to get in quickly and want to notify you as soon as possible whether we will be able to assist you.

We will review this submission within the next seven days.

If you do not receive an email or voicemail within seven days then, after review of submission, it has been determined that we are unable to assist you at this time. You may resubmit this form in three months to see if we have greater availability or new resources to help.

If we feel we may be able to assist you, we will email you a link to our patient portal (patient fusion) which you will sign into from your email, confirming with the cell phone number you have given us below.

Once you are established in the patient portal, send a message to Dr. Grace through the portal, stating you have activated your account and we will send you the new patient paperwork and next steps towards establishing.

YOU ARE STILL NOT CONSIDERED AN ACTIVE PATIENT OF THIS OFFICE UNTIL AFTER YOUR FIRST FACE-TO- FACE VISIT WITH DOCTOR GRACE WHEN BOTH OF YOU AGREE TO ENTER INTO A DOCTOR-PATIENT RELATIONSHIP.
We are IN-NETWORK with the following insurances and able to verify benefits the fastest.

1. Medicare
2. Aetna Insurance- [Majority of Policies IN-Network Including -Strategic Resource Company- [ Aetna Specialty Group Insurance]
3. Cigna Insurance
4. Cigna Great West
5. Tri Care Humana Military Policies
6. ChampVa-
7. GEHA

We are out-of-network with all other insurances and the verification of benefits can take considerable time, up to a month depending on the policy and current staff availability.

In addition, the following plans generally have limited out-of-network benefits and end up being largely self-pay. Keep in mind that psychiatric care tends to be very expensive (often several thousand dollars over the first months of treatment). It is usually much more cost-effective to see a provider within your insurance.

1. BCBS Primary Insurance Policies [ All Policies]

2. FHCP-Medicare Advantage Plans- Affiliate of BCBS

3. Freedom, Insurance [ All Plans]

4. Ultimate Insurance [ All Plans]

5. Beacon Health Options [ All Pland]

6. Magellan Health- [ All Plans]

7. Optimum Healthcare

8. WellCare Insurance
What are your reasons for seeking mental health care at this time? (Select all that apply)*

Current Heavy Substance Abuse/Misuse (List Substance Below in Other)DepressionAnxietyConcentration Difficulties (ADD, Traumatic Brain Injury)BipolarAngerCognitive Decline/ DementiaOther
ABILITY TO COME TO OFFICE/ACCESS CARE*

EASY- I can EASILY come to the office for routine appointments.DIFFICULT - Due to other constraints (health, financial, social) it is DIFFICULT for me to come to the office. I strongly prefer TELE-HEALTH visits whenever possible.
ABILITY TO ACCESS/USE TECHNOLOGY/INTERNET*

EASY- I can EASILY access the internet for my health care with a high-speed connection. This includes accessing of websites, portals, filling out online forms, and connecting to providers.DIFFICULT - Due to constraints (health, technology, social) it is DIFFICULT for me to access the internet for my health care. I strongly prefer as much communication as possible be in-person, via telephone, or through the mail.
EMAIL AND TELEPHONE SECURE AND PRIVATE CONTACT*

EMAIL AND TELEPHONE-You may contact and leave private information including patient link and portal information via email and telephone. This includes my consent for reminders and telemedicine.NO PRIVATE INFORMATION- I do not wish to communicate any private information via email or telephone including telemedicine. Please just call me to schedule an appointment to do everything in the office.
Date of Birth*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
YOU MUST HAVE AN ACTIVE PRIMARY CARE PHYSICIAN (YOU HAVE SEEN IN LAST YEAR) AT THIS TO ESTABLISH WITH THIS OFFICE. WHO IS YOUR CURRENT PRIMARY CARE PHYSICIAN? PLEASE PROVIDE A PHONE NUMBER AS WELL TO ALLOW US TO VERIFY YOUR STATUS WITH THEM.*
YOU MUST HAVE HEALTH INSURANCE THAT COVERS LABORATORY AND IMAGING SERVICES. WHO IS YOUR CURRENT PRIMARY INSURANCE PLAN (INCLUDE FULL PLAN NAME, POLICY NUMBER, GROUP NUMBER, NAME OF MAIN BENEFICIARY) AND CONTACT INFORMATION TO VERIFY.*
SECONDARY INSURANCE, IF APPLICABLE (INCLUDE FULL PLAN NAME, POLICY NUMBER, GROUP NUMBER, NAME OF MAIN BENEFICIARY)..IF NONE WRITE "NONE"*
WHAT ARE YOUR CURRENT MEDICATIONS AND DOSES? Type "none" if none.*
MAY WE VERIFY ANY CONTROLLED PRESCRIPTIONS ABOVE AS ACTIVE BY CONTACTING THE FLORIDA DRUG ENFORCEMENT AGENCY?*

YESNO
If you have no insurance or out-of-network insurance, how would you like to proceed?*

Please verify my benefits prior to scheduling, I understand this may take considerable time if I am out-of-network.I am willing to be self-pay initially. Any insurance credits received will be returned to me once benefits are verified. I understand that self-pay psychiatric care can be very expensive (up to thousands of dollars the first several months) depending on my clinical needs.
NOTE
WE MAY NOT BE ABLE TO ACCEPT YOU AS A PATIENT.

THERE ARE MANY POSSIBLE REASONS FOR THIS:

WE MAY NOT HAVE ENOUGH AVAILABILITY CURRENTLY TO ASSIST WITH THIS ISSUE.

THERE MAY BE A CONFLICT OF INTEREST.

IT MAY BE OUTSIDE OUR EXPERTISE

THIS NON-ACCEPTANCE MAY OCCUR AFTER THIS PAPERWORK, THE INITIAL PAPERWORK, OR INITIAL VISIT. YOU ARE NOT A PATIENT OF THIS OFFICE UNTIL BOTH YOU AND DOCTOR GRACE AGREE TO ENTER INTO A DOCTOR-PATIENT RELATIONSHIP AFTER YOUR FIRST VISIT.

We will review this information and reach out to you within seven days. If you have not heard from a member of the staff within seven days then we are unable to accomdate you at this time...please try again in 3-4 months as we attempt to expand our services.
By signing below I understand and accept the above submission.*

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