New Psychiatric Consent and Demographics 2023

PATIENT INFORMATION
Patient Legal Name: First Middle Last
First Middle Last
Name you would like to be called:
Gender:
Legal Gender:
Gender Assigned at Birth:
Pronouns: he/him. she/her. they/them. or _________
Ethnicity or you can leave blank:
Preferred Language if not English:
Social Security Number
Date of birth:
Address: Street, City, Sate, Zip code
Billing address if different - if not write same
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Email address:
Emergency contact/next of kin and relationship:
Address of Emergency contact: street, city, state, zip
Emergency contact home/cell phone
Emergency Contact Work phone
If applicable, who has legal guardianship over the patient? Please list name and phone number
With whom may we discuss your care (name and relationship)?
Name and Relationship
Phone Number
Please enter valid phone number with whom person we can discuss your care.
With whom else may we discuss your care (name and relationship)?
Name and Relationship
Phone Number
Please enter valid phone number with whom person we can discuss your care.
Dr. Sastry or other staff members may speak to the person indicated above (spouse, family member, friend) about my medical condition. This may include information related to mental/behavioral health, substance abuse, sexually transmitted disease, HIV status and reproductive medicine unless specified below. Initial or write decline
Initial to indicate consent

AUTHORIZATIONS
Yes I allow detailed Voicemail as indicated below (initial here).
Initial
GPC may leave detailed voice messages at my home #
Please re-enter your home phone if you wish for us to leave detailed voicemail.
GPC may leave detailed voice messages at my cell #
Please re-enter your cell phone if you wish for us to leave detailed voicemail.
Allow text: GPC may text message me at my cell phone to confirm appointments (Initial here)
I DO want email - Email consent: GPC may send my personal health information via email. I understand that email may be unencrypted and that this carries a risk of third-party gaining access. I also understand that emails may be part of my permanent medical record. I also give permission for GPC to communicate via email to my specialists and other outside providers as indicated through my signed release of information form. (initial here) or type N/A
Initial
I DO NOT want to allow email. I do not wish to have email initiated from GPC; I understand that if I email GPC they may respond to my request via email. (initial here) or type N/A
Leave blank if you DO want email
Preferred Pharmacy and cross streets
NOTICE OF PRIVACY

By initialling below, I acknowledge that I have had the opportunity to review the Notice of Privacy Practices. This signed acknowledgement form of my review will be retained in my medical record, in accordance with HIPAA Privacy Act regulations. It is also available on our website greenlakepsychiatric.com.

I also acknowledge that GPC will call to leave reminder phone calls with date and time, name of provider; on occasion reminder post cards may be sent as well.
Initial below to accept the Notice of Privacy
Initial
ADJUNCTIVE TREATMENT:

By initialling below, I understand that GPC is not assuming the role of “primary care provider” rather I am being provided specific care for a procedure, vaccination, or for specialty care. This may include ongoing care for a specific service and may require one or several visits. I will be financially responsible for each separate visit.
Initial below to consent to adjunctive treatment
Initial here
NOTICE OF RIGHTS OF MINOR TO SEEK CARE:

Under Washington State law, minors have the right to consent to certain health care without a parent or guardian’s consent. While we encourage minor patients to involve a parent, guardian or other trusted adult in all aspects of health care, if a minor consents to care as allowed by law, he or she can request confidentiality. That would prohibit us from releasing this information to anyone, including a parent or guardian, without the minor’s express written consent. These situations include:

If the minor is an emancipated (legally independent) or married to someone at or above age 18.
In the event emergency care is required.
For birth control and pregnancy-related care at any age.
For mental health, drug and alcohol abuse treatment beginning at age 13.
For sexually transmitted diseases, including HIV, beginning at age 14.
CONSENT TO BE TREATED AND ADVANCED CONSENT TO TREAT MINORS:

I give permission and authorize the providers and staff of Greenlake Primary Care to examine and treat me or the minor listed. If treatment is for a minor, I hereby give permission for the patient to receive treatment. In the rare even that I cannot be reached, I authorize GPC to institute any necessary care for the patient, including hospitalization.

This authorization is in effect until rescinded in writing.

With my signature below, I acknowledge and understand that this information will be kept in my medical record according to and the instructions above will be honored until revoked by me in writing. It is my responsibility to notify GPC should I change one or more of the telephone numbers listed above.
Signature (must be signed by parent/legal guardian if patient is under the age of 18)

Clear
Today's Date

MonthDayYear
Date
Guardian's name (person signing this form)

Greenlake Psychiatric Care Treatment Policies
Expectations of Care - As a patient of Greenlake Psychiatric Care you can:
- Expect to be treated with respect and consideration.
- Expect us to strive to meet your individual needs.
- Expect your patient information to be kept confidential unless specifically requested or indicated otherwise by law.
- Expect care in a setting that does not practice any discrimination.
- Expect to be an active participant in your care, including receiving information about your condition and options for treatment.
- Expect to have grievances addressed appropriately.
Office Hours

Dr. Sastry’s office hours vary. Currently, her hours are Tuesday and Wednesday 8:30 am to 4:30 pm, and Friday from 8:30am to 12pm.

Telemedicine consent

Telemedicine is the use of electronic information and communication technologies by a healthcare provider used to deliver services to an individual when he/she is located at a different location or site than I am.
If you receive care through telemedicine, it will be done through a two-way video link-up. The healthcare provider will be able to see your image on the screen and hear your voice. You will be able to hear and see the healthcare provider.
The laws that protect privacy and the confidentiality of medical information including (HIPPA) also apply to telemedicine.
All financial terms that apply to in person visits as written in our financial policy apply to telemedicine.
You have the right to withdraw consent to the use of telemedicine in the course of care at any time, without affecting your right to future care or treatment.
By signing the consent to care document you are consenting to telemedicine if you schedule your appointment that way.

Appointments:

Intake forms, consent to treat, and financial policy must be completed and signed prior to your first appointment. If any forms are missing or not signed, the appointment may need to be rescheduled.
New patient appointments last for 60 to 90 minutes, follow up appointments are typically 20-30 min.
Dr. Sastry reserves your appointment time for you and will make every effort to start your appointments on time.
It is expected that you will make every effort to be ready for your appointment on time with the understanding that if you are late, you will be seen for the time remaining in your appointment, (if more than 10 minutes of appointment time is left) but additional time will not be added.
There is a $75 late cancellation/no show/late cancel fee (see financial policy)

Billing

Co-pays, balances and out of network payments are due at the time of your appointment. We request that you leave a credit card on file for telemedicine visits and outstanding balances. You are responsible for asking your insurance company if Dr. Sastry is in network prior to your visit and for updating Greenlake Psychiatric if there are any changes to your insurance.

Communication

Dr. Sastry can be reached by leaving a message with a staff member or on voicemail at (206) 524-5656 during regular office hours Monday through Friday. Please be as specific as possible when providing information in order to better manage your care. Dr. Sastry (or a staff member) will try to address any issues within 24 hours, or 1 business day. Any medication issues may take up to 48 hours.

Dr. Sastry DOES NOT communicate over email in order to better maintain issues of privacy and safety. If you choose to send emails to the practice please understand that they may be delayed and urgent messages should not be sent in email.

After hours/emergency

Dr. Sastry manages her calls after hours through an answering service. This is for URGENT concerns only. If there is an emergency, you will agree to go to the emergency room or call a crisis. Dr. Sastry cannot do emergency assessments over the phone.

Do not page Dr. Sastry after hours for refills- for after hours refills please leave a message on the staff message line and these will be given to Dr. Sastry during office hours.

Prescription Policies

Prescriptions will be managed during appointments; refills will be provided during appointments to last until next recommended visit. It is your responsibility to manage your supply of medication as the processing of urgent requests cannot be guaranteed. Any controlled substances (stimulants, sleep, short-acting anti-anxiety meds, etc.) need to be monitored closely with frequent visits. Refills for those medications will not be called in and will require an office visit. Dr. Sastry does not prescribe pain medications or medications to acutely manage withdrawal. Dr. Sastry will also only refill medications that she prescribes. If you are prescribed medications by Dr. Sastry, you will agree to only get those medications from her and inform her of any other similar medications you are prescribed. Dr. Sastry can utilize the Washington State Prescription Drug Monitoring Program at her discretion and any suspicious activity or results can alter your treatment.

Confidentiality

You can expect that your status as a patient and any accompanying information is confidential unless we explicitly have your written consent. This applies to picking up prescriptions, providing information to schools, faxing information, sharing information with other providers, etc. Information, such as diagnoses, appointments, treatment plans, etc., can be shared with insurance companies that we are billing for you. You are able to request a copy of your medical records.

Social Media and Networking

Dr. Sastry does not engage in social media or networking with patients in order to maintain confidentiality and professional boundaries.

Patient Satisfaction and Grievances

Dr. Sastry and her staff work to provide a high-quality, individualized, and effective experience. If you are in any way dissatisfied with your care, please address your concerns directly with Dr. Sastry or Dr. Tess Moore (Owner).

Financial Policy

Greenlake Psychiatric participates with a wide variety of insurance plans including: Premera and Regence. Dr Sastry is not a participating provider with United, Tricare, Medicare nor Medicaid. Insurance coverage and contracting may change and it is your responsibility to know if we are covered by your plan.

As a patient or guarantor, we ask you to know your insurance plan. Before your visit, call the toll free number on the back of your insurance card. Make sure you know if Dr Sastry is an in network contracted provider.
- Bring your insurance card to every visit.
- Tell us if your insurance or mailing address has changed.
- Pay your co-pay or balance at the time of your visit.
Cancelation policy:

For all new and established patient appointments, we require at least 48-hour notice if you are unable to keep your appointment. Missing an appointment and/or canceling with less than 48 hours notice, will result in a cancellation fee. You will need to pay this fee before any future appointments will be made.

New patients are allowed one missed appointment then they will not be allowed to schedule.
Established patients - three missed appointments within 12 months may result in dismissal from the practice.

There is a $75 late cancellation/no show/late cancel fee

We accept all credit cards, debit and HSA cards, and ACH transfers. We will keep a credit card number on file for your convenience. Checks returned for insufficient funds will result in an immediate charge of $35.00 against your account.

Billing:

Greenlake Psychiatric will submit bills to insurance companies on your behalf when we are in-network providers. As a patient, you can expect that we will provide accurate and timely billing. If we do not contract with your insurance company, we will provide you with a superbill and receipt of payment for you to submit to your insurance company. There is no guarantee of any reimbursement if we are out of network.

Insurance Release of Benefits and Release of Information:
I authorize Greenlake Psychiatric to request and directly collect, on my behalf, all private insurance coverage benefits due for products and services.
I authorize insurance benefits to be paid directly to the provider or clinic.
I authorize the providers or insurance company to release any healthcare information necessary to facilitate the processing of claims and audit of payments.
I understand that I am financially responsible for any co-payments, deductibles, balances due, and charges for services not covered by my insurance plan
If insurance benefits are paid directly to me, I will endorse these checks for such payments to Greenlake Psychiatric.

When patient turns 18 years old, they become the guarantors of their account. They will be asked to review their own financial agreements the first time they have a visit after turning 18.

I have read and understand this policy. A copy will be kept in my chart and a copy may be furnished to me at my request. All authorizations as above will remain in effect until rescinded in writing.
Signature

Clear

Credit Card and/or ACH withdrawl Authorization:
I authorize Greenlake Primary Care to charge my credit card or ACH account on file for all charges as well as any co-pays, or balances that are due. These include charges collected for labs, medications, late fees as above, and other incidentals that will be explained to me prior to any payments being rendered. Credit card numbers and ACH will be entered directly by me or staff into the secure payment system HINT or directly into our online credit card terminal through Transaction Express. No card numbers or bank information will be stored in my chart or in the office and the card number or bank account information cannot be accessed once entered.
- I can ask and receive a statement of my account which the practice will provide within 5-7 business days
- Start date of authorization is pursuant to start date of my signature below.
- The credit card and/or ACH authorization is in effect until rescinded in writing.
Signature

Clear

Primary Insurance
Policy Number
Group Number
Guarantor For Primary Insurance

First NameLast Name
Relationship to patient:
Insurance Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone Number
Please enter a valid phone number.
Guarantor Date of Birth

MonthDayYear
Date
Secondary Insurance

Should be Empty: