• JOHN W. GRACE M.D.,P.A.

    CHECK-IN & PAYMENT FORM

    PART I OF THIS FORM

    HAS ALL MANDANTORY COMPONETS

    SECOND PART VOLUNTARY

        You are no longer required to do a check in between visits.   You may submit after completing all sections in part I.  However the second component has valuable scales for anxiety, ptsd, emotional regulation, and disability assessment if you would like to complete them.    

         You will see a Green Check Mark and "Thank You! Your submission has been received." on the screen when this is done successfully. Please make sure you see this before exiting the screen, otherwise your form has not been submitted.

          NOTE:  FAILURE TO PROPERLY SUBMIT THIS FORM OR COMPLY WITH PAYMENT SCHEDULE BELOW MAY RESULT IN SHORTER SUPPLY OF PRESCRIPTIONS WHILE WE DETERMINE APPROPRIATE ACTION.

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  • MEDICATIONS NEEDED 

    *NOTE:  TRY TO GET THESE REQUESTS IN ABOUT SEVEN DAYS EARLY AS THERE CAN BE MULTIPLE DELAYS (MISCOMMUNICATIONS, SUPPLY, INSURANCE, ETC.) 72 HOURS AFTER YOU SUBMIT THIS FORM,  VERIFY THAT THE PRESCRIPTIONS ARE AT THE PHARMACY.  IF NOT, CONTACT DR. GRACE ON HIS CELL PHONE.

  • REMEMBER PAYMENTS

    If you have a balance greater than $200.00, we may shorten the length of prescriptions to determine whether you can afford care with this office.  

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  • BY YOUR SIGNATURE BELOW YOU AGREE TO THE FOLLOWING:

    1.  I am NOT currently a danger to myself or others.  Emergencies should be dealt with by contacting 911 or presenting to the nearest emergency room.  The Vines in Ocala, Springbrook Hospital, Shands Hospital.  

    2.  I have Dr. Grace's personal cell phone number and will contact him if there is a serious lapse in my care, understanding that he will return my call or deal with my issue within 24 hours. 

    3.  I have read and accept the policies and general instructions of John W. Grace, M.D.

    Link here:  https://www.johnwgracemdpa.com/instructions-policies 

    Including the following areas:

    POLICIES
    - PRIVACY

    - BALANCES, LATE CANCELATIONS, AND FEES

    - VISIT REQUIREMENTS AND TERMINATION

    - THIRD PARTY PAPERWORK

    - UNDERSTANDING AND MINIMIZING RISKS OF MEDICATIONS

     

    GENERAL INSTRUCTIONS

    HOW TO RELAX BY STRESSING YOURSELF OUT EACH MORNING.

    HOW TO BALANCE YOUR IMPROVEMENT

    HOW TO SEEK SERENITY MORE THAN EXCITEMENT

    HOW TO KEEP A GOOD ROUTINE

    HOW TO SEEK SUPPORT FOR GOOD DECISIONS

    HOW TO BE MORE MINDFUL

    HOW TO TRACK YOUR SYMPTOMS

    HOW TO AVOID DESTRUCTIVE IMPULSES

     

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  • JOHN W. GRACE M.D.,P.A.

    CHECK-IN FORM

    PART II (OPTIONAL NOT REQUIRED)

    THIS SECTION IS VOLUNTARY AND ALLOWS YOU TO UPDATE INFO OR ADD ADDITIONAL RATING SCALES.  YOU MAY LEAVE THESE SECTIONS BLANK IF THEY ARE UNCHANGED FROM YOUR LAST VISIT.   YOU MAY ALSO UPDATE THEM.

    IF YOU WOULD LIKE TO TRACK THE SEVERITY OF YOUR SYMPTOMS OF ANXIETY, POST-TRAUMATIC STRESS DISORDER, EMOTIONAL REGULATION OR DISABILITY YOU MAY COMPLETE THE FOLLOWING SCALES.  YOU CAN ALSO SIMPLY CUT, PASTE, AND UPDATE YOUR PREVIOUS TREATMENT PLAN FROM PATIENT FUSION IF IT IS AVAILABLE TO YOU.   

     

  • IMPORTANT ANNOUNCEMENTS
     

    Prior Authorizations is one of the most time consuming difficulty for obtaining medicaitons even generic.  This process can take up to a month for us at times due to back log.  

     

    If you have a formulary, if you can upload a link to it here it will be helpful.

     

  • HOW WILL OUR PROGRESS BE MEASURED:

     We are going to be using a number of evidence-based psychological scales to track  progress.  The first two scales are specific to anxiety, and post-traumatic stress disorder.  The third scale measures how we handle emotions and stress.   The last is an assesment of disability.

     

  • GAD-7: TRACKS SEVERITY OF ANXIETY

     

    This scale measures generalized worry and anxiety.

     

     

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  •   PCL-5

    This scale tracks the severity of Post Traumatic Stress Disorder


    Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.

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  • The Difficulties in Emotion Regulation Scale (DERS) is an instrument measuring emotion regulation problems.

    This scale measures an integrative conceptualization of emotion regulation.

    A substantial body of research has shown significant positive associations between scores on the DERS (specifically the total score) and symptoms of a range of psychological disorders, including borderline personality disorder (Gratz et al., 2006), generalized anxiety disorder (Mennin et al., 2002), substance use disorders (Fox et al., 2007; Gratz and Tull, 2010), social anxiety (Rusch et al., 2012), health anxiety (Bardeen and Fergus, 2014), post-traumatic stress disorder (Ehring and Quack, 2010), and bipolar disorder (Becerra et al., 2013; Van Rheenen et al., 2015).

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  • The next assessment is a WHODAS 2.0 which is a standardized self-assessment of disability.  Answer each of the following questions regarding  how much difficulty did you have in the following areas using the following scale from 1-5.

     

    (1)= no difficulty  

    (2)= mild difficulty  

    (3)= moderate difficulty  

    (4)= severe difficulty  

    (5)= extreme difficulty  or unable to accomplish at all

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  • UPDATE YOUR WELLNESS PLAN

     


    If you haven’t done a formal impulse control plan see the link here and do so.

     


    https://form.jotform.com/203133142590040

     


    Doing it and reviewing it is one of the most important things you can to maintain productivity and mental wellness.  After you do it, make a copy.  Then periodically paste and update your impulse control plan here.

     

    TRIGGERS

    WARNING SIGNS

    COPING SKILLS, PLACES, AND PEOPLE

    CHANGES TO ENVIRONMENT TO AVOID DESTRUCTIVE IMPULSIVITY

    PROFESSIONALS I CAN REACH OUT TO


     

    DIAL 911 OR GO TO ANY EMERGENCY ROOM FOR PSYCHIATRIC EMERGENCIES AS WELL AS MEDICAL


    Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255)
    Citrus County Lifestream Crisis Line: 866-355-9394
    Veteran Crisis Line:  1-800-273-8255. (Text 838255)
     
     
     
    Local Urgent Psychiatric Services
     

    The Vines Psychiatric Hospital
    24 hour Emergency care and Hospitalization
    866-671-3130
    https://thevineshospital.com/
    3130 Southwest 27th Ave. Ocala, FL 34471
     

    Springbrook Psychiatric Hospital
    24 hour Emergency care and Hospitalization
    352-600-3288
    https://www.springbrookhospital.org/
    7007 Grove Road, Spring Hill, FL 
     

    Lifestream Behavioral Center
    Medication, therapy and 24 hour Emergency care and Hospitalization
    866-355-9394
    https://www.lsbc.net/

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