NEW PATIENT REGISTRATION

PLEASE BE AWARE: Astra Behavioral Health, LLC DOES NOT ACCEPT Workers Comp Claims, Employee Assistance Programs, or Automotive Insurance Policies. 

Please visit www.astrabh.com for more information about our office hours of operation, phone numbers and FAX numbers

I hereby authorize payment of medical benefits billed to my insurance by ASTRA BH. I have listed all health insurance plans from which I may receive benefits. I hereby accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I agree to pay all copayments, coinsurance, and deductibles at the time services are rendered. I agree to provide ASTRA BH with the most current and up-to-date insurance(s) information within 30 DAYS of any changes to my insurance information; to include losing insurance and transitioning into a self-pay status. I accept responsibility for fees that exceed the payment made by my insurance, and/or if ASTRA BH or the provider do not participate with my insurance. I hereby authorize ASTRA BH to use and/or disclose my health information, which specifically identities me or which can reasonably be used to identify me, to carry out my treatment, payment, and healthcare operations. I understand that while this consent is voluntary, if I refuse to sign this consent, the ASTRA BH can refuse to treat me. I understand this authorization can only be revoked in writing. If I revoke my consent, such revocation will not affect any actions that ASTRA BH provider took before receiving my revocation.

Providing this information allows your ASTRA provider to send a letter to your PCP stating you are being seen by a provider at ASTRA. If you wish to decline the release of this letter to your PCP, please mark the “DECLINE RELEASE” box below.

PLEASE LIST ANY PERSON(S), WHO YOU GIVE AUTHORIZED ACCESS TO THE SELECTED HEALTH INFORMATION BELOW

We can provide strength, hope, resources, and skills in these areas through Targeted Case Management, Supported Employment, and Peer Support services. If you answered “YES” to any of these questions, we will contact you to assist in getting the help you need.

Controlled substances (benzodiazepines, amphetamines, buprenorphine, etc.) are very useful, but have a high potential for misuse and are, therefore, closely controlled by our local, state, and federal government. As a patient of Astra Behavioral Health, LLC, before receiving medications listed as Controlled Substances, it is required that you agree and understand the following notices and policies: Please carefully read the information below.

Benzodiazepines are prescription drugs used to treat conditions like Anxiety, Insomnia, and seizures. Examples of these drugs include: Alprazolam, Clonazepam, Diazepam, and Lorazepam. The FDA has applied a Black Box Warning (an alert for consumers) that the use of opioids and benzodiazepines together has serious risks that include unusual dizziness/lightheadedness, extreme sleepiness, slowed or difficulty breathing, coma and death. Alcohol increases these risks. It is Astra Behavioral Health, LLC policy to NOT prescribe benzodiazepines to patients who also use opioids. If a patient is already prescribed both, the prescriber has a responsibility to taper the benzodiazepines as part of the treatment plan. These patients must be monitored at appropriate intervals and visits may be more frequent.

Buprenorphine (Suboxone or Sublocade) are medications used in combination with naloxone to treat opioid addiction. Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone, hydrocodone, codeine, morphine, methadone, and many others. Buprenorphine is an opioid analgesic medication, while naloxone is an opioid antagonist drug, and the two are combined in a 4 to 1 (buprenorphine to naloxone) ratio. The naloxone is present in the tablet to prevent diversion to injected abuse of this medication. Injection of buprenorphine/naloxone by a person who is addicted to opioids will produce severe opioid withdrawal.

I have been fully informed of the above treatment agreement points and have full understanding of my duties as a patient of Astra Behavioral Health, LLC in regards to the controlled substances I may be prescribed.

My signature affixed below affirms that I have received, read, fully understand, and agree to the contents of each document listed above, and should I have any questions or are unable to view the electronic copy of these documents provided above, I will ask a staff member of Astra Behavioral Health, LLC for assistance.

Furthermore, my signature affixed below acknowledges I wish to have treatment given to me, my child, or my ward by Astra Behavioral Health, LLC. Also, my signature affirms I have been informed of the treatment and procedures necessary, which will be performed by a psychiatrist, psychiatric nurse practitioner, therapist, and/or assisted by other staff members of Astra Behavioral Health, LLC; and my authorization to receive such treatment and procedures is hereby granted.