lifeexcelbehavioralhealth.com-NewPatientPaperWork

Life Excel/New Patient Information
Name*

First NameMiddle NameLast Name
Address*
Home Phone
Cell Phone
Email Address*
Patient Social Security#
Sex*

MaleFemale
Marital Status*
Date Of Birth*

MonthDayYear
Patient Employer Name
Patient Employee Address
Employer Phone
Insurance/Responsible Party Information
Relationship to Patient:*
Name (if different from above)

First NameMiddle NameLast Name
Address*
Social Security #*
Date of Birth*

MonthDayYear
Date
Employer*
Insurance Information/Primary Insurance
Name of Insurance*
Address of Insurance Company*
Insurance Phone*
Identification#*
Group#*
Employer Phone*
Employer*
Insurance Card*

Cancelof
Secondary Insurance
Name of Insurance
Address of Insurance Company
Phone
Identification#
Group#
Primary Doctor Phone
PrimaryDoctor
Referring doctor (if applicable)
Emergency Contact Information
Emergency Contact Name*
Emergency Contact Phone*
Relationship to patient*
Assignment and Release: I hereby authorize my insurance benefits to be paid directly to the physician and I am financially responsible for non-covered services. I also authorize the physician to release any information required in the processing of this claim and all future claims. If my accounts are sent to a collection agency, I agree to pay all collection and attorney fees.
Patient Signature (parent of guardian if minor)*

Clear
Date*

MonthDayYear
Authorization to release health information (Doctors or individuals)
Name*

First NameLast Name
Date Authorization expires: * (Unless otherwise noted this authorization will remain in effect one year from the date signed)
Release of Information
I understand that once “this facility” discloses my health information by my request, it cannot guarantee that recipient will not re-disclose my health information to a third party. The third party may not be required to aibe by this authorization or applicable federal and any state laws governing the use and disclosure of my health information.

I may make a request in writing at any time to inspect and/or obtain a copy of my health information maintained at this facility as provided in the Federal Privacy Rule 45 CFR (164.524)

My records are protected and cannot be disclosed without written permission.

This authorization will remain in effect for one year or I provide a written notice of revocation to the Medical Records Department.
Signatureof Patient or Legal Representative *

Clear
Date*

MonthDayYear
Printed Name*

First NameLast Name
Email*
example@example.com
Signature of Witness (optional)

Clear
Life Excel
Patient Name*

First NameLast Name
DOB*

MonthDayYear
Date
Preferred Pharmacy
Name of Pharmacy*
Address*
Phone*
Fax
Medical History (Please Mark)*

AllergiesAnemiaAnxietyArthritis conditionsAsthmaArterial fibrillationBleeding problemsBPHCADCancerCardiac ArrestCeliac diseaseChest painCHFChronic fatigue syndromeDepressionDiabetesDrug/alcohol abuseErectile dysfunctionFibromyalgiaGerdHeart diseaseHigh cholesterolHyperinsullnemiaHyperllpidemiaHypertensionHyperthyroidHypogonadismHypothyroidIbsKidney problemsMenopauseMigraines/headacheNeuropathyOnchomycosisOsteoporosisPulmonary embolismSeizure disorderShortness of breathSinus conditionsStrokeSyndrome XTremorsNone of the above
Others
Mental Health Issues
Surgical Histories (please list all procedures including month and year of procedure)
Current Medication:
Please list any medications

Type a question

	Medication	Dosage

Please initial and sign the following disclosures:
* Life Excel accepts most major insurance . In the event that your insurance does not cover your appointment or there is a lapse in your insurance or cancellation, please note that you w ill be billed and the total amount will be your responsibility.
* Life excel charges a $ 50. Cancellation fee for all no show visits cancelled without 24 hour notice. Please take not e of your appointment date/time .
* All co-pays are collected date of Service prior to your appointrnent. There are no exceptions to this rule.
* As of Sept . 1, 2018 any patient carrying a balance larger than $50. will not be able to be seen or to schedule an appointment. This includes charges for No Show visits or cancellations made without 24 hour notice.
* In our continuing effort to provide all of our patients with the best care possible, we must have seven (7) days prior notice to consider any request for a prescription refill. It is imperative that you keep your scheduled appointments a s well as keep track of your remaining medication quantity.
Print Name*
Date*

MonthDayYear
Signature*

Clear
Guardians Signature(If applicable)

Clear

	Current	Past	If past, please explain why it was stopped
Anafranil (clomipramine)
Trintellix (vortioxetine)
Celexa (citalopram)
Cymbalta (duloxetine)
Desyrel (trazodone)
Effexor/Effexor XR (venlafaxine)
Elavil (amitriptyline)
Emsam (selegiline)
Fetzima (levomilnacipran)
Lexapro (escitalopram)
Luvox (fluvoxamine)
Norpramin (desipramine)
Pamelor (nortriptyline)
Paxil (paroxetine)
Pristiq (desvenlafaxine)
Prozac (fluoxetine)
Remeron (mirtazapine)
Sinequan (doxepin)
Tofranil (imipramine)
Viibryd (vilazodone)
Wellbutrin (bupropion)
Zoloft (sertraline)

	Current	Past	If past, please explain why it was stopped
Depakote (valproic acid)
Eskalith (lithium)
Lamictal (lamotrigine)
Neurontin (gabapentin)
Tegretol (carbamazepine)
Topamax (topiramate)
Trileptal (oxcarbazepine)

	Current	Past	If past, please explain why it was stopped
Abilify (aripiprazole)
Caplyta (lumateperone)
Clozaril (clozapine)
Fanapt (iloperidone)
Geodon (ziprasidone)
Haldol (haloperidol)
Invega (paliperidone)
Latuda (lurasidone)
Mellaril (thioridazine)
Navane (thiothixene)
Prolixin (fluphenazine)
Rexulti (brexpiprazole)
Risperdal (risperidone)
Saphris (asenapine)
Seroquel (quetiapine)
Thorazine (chlorpromazine)
Trilafon (perphenazine)
Vraylar (cariprazine)
Zyprexa (olanzapine)

	Current	Past	If past, please explain why it was stopped
Ambien (zolpidem)
Ativan (lorazepam)
Belsomra (suvorexant)
Buspar (buspirone)
Dayvigo (lemborexant)
Inderal (propranolol)
Klonopin (clonazepam)
Librium (chlordiazepoxide)
Lunesta (eszopiclone)
Restoril (temazepam)
Serax (oxazepam)
Tranxene (clorazepate)
valium (diazepam)
Xanax (alprazolam)

	Current	Past	If past, please explain why it was stopped
Adderall (amphetamine salts)
Dexedrine (dextroamphenidate)
Concerta (methylphenidate)
Ritalin (methylphenidate)
Metadate (methylphenidate)
Daytrana (methylphenidate)
Intuniv (guanfacine)
Focalin (dexmethylphenidate)
Kapvay (clonidine)
Tranxene (clorazepate)
Strattera (atomoxetine)
Qelbree (viloxazine)