ASTRA BH PATIENT REGISTRATION
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  • NEW PATIENT REGISTRATION

    Page 1 of 5

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

  • DATE OF BIRTH*
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • HOW WOULD YOU LIKE TO RECEIVE APPOINTMENT REMINDERS?
  • IS YOUR TREATMENT COURT-ORDERED?*
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  • WHICH SERVICES ARE YOU INTERESTED IN RECEIVING FROM ASTRA BEHAVIORAL HEALTH?*
  • ARE YOU CURRENTLY ENROLLED IN AN IOP OR MAT PROGRAM OUTSIDE OF ASTRA BEHAVIORAL HEALTH?*
  • ARE YOU UNDER THE CARE OF A PARENT/GUARDIAN?*

  • GUARDIANSHIP AND/OR CUSTODY PAPERWORK ARE REQUIRED TO BE GIVEN TO ASTRA BH OFFICE STAFF PRIOR TO INITIAL APPOINTMENT

  • Format: (000) 000-0000.
  • DOES THE PATIENT RESIDE WITH PARENT/GUARDIAN 1?*
  • PARENT/GUARDIAN 1 DATE OF BIRTH*
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  • GUARDIANSHIP AND CUSTODY PAPERWORK ARE REQUIRED TO BE GIVEN TO ASTRA BH OFFICE STAFF PRIOR TO INITIAL APPOINTMENT

  • PARENT/GUARDIAN 2 DATE OF BIRTH
     / /
  • Format: (000) 000-0000.
  • DOES THE PATIENT RESIDE WITH PARENT/GUARDIAN 2?*

  • HEALTH INSURANCE INFORMATION

  • DO YOU HAVE HEALTH INSURANCE?*
  • DO YOU HAVE A SECONDARY HEALTH INSURANCE PLAN?*
  • DO YOU AGREE TO SELF-PAY FOR SERVICES PROVIDED TO YOU BY ASTRA BEHAVIORAL HEALTH?*

  • IF YOU AGREE TO SELF-PAY FOR SERVICES, PLEASE SEE THE SELF-PAY APPLICATION/AGREEMENT LINKED *HERE*

  • POLICY HOLDER'S RELATIONSHIP TO PATIENT*
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  • POLICY HOLDER'S RELATIONSHIP TO PATIENT
  • UPLOAD INSURANCE PHOTOS HERE
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  • WHICH ASTRA BEHAVIORAL HEALTH LOCATION ARE YOU INTERESTED IN RECEIVING SERVICES AT?*

  • 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.

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  • TODAYS DATE*
     / /
  • PATIENT'S DOB*
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  • CURRENT PRESCRIBED MEDICATIONS

  • ARE YOU CURRENTLY TAKING ANY PRESCRIPTION MEDICATIONS?*
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  • DO YOU USE RECREATIONAL DRUGS OR ALCOHOL?*
  • HAVE YOU EVER HAD GENETIC TESTING (i.e. GENESIGHT)?*

  • PRIMARY CARE PROVIDER INFORMATION

  • 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.

  • DO YOU WISH TO PROVIDE YOUR PRIMARY CARE PROVIDER'S CONTACT INFORMATION?
  • Format: (000) 000-0000.

  • EMERGENCY CONTACT INFORMATION

  • DO YOU HAVE AN EMERGENCY CONTACT?*
  • Format: (000) 000-0000.

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

  • PATIENT'S DOB*
     / /

  • RESOURCES

    At Astra Behavioral Health, we are committed to providing the best resources to meet your mental health needs. We understand that there are often challenges and we are here to help. To get started, Please choose “YES” or “NO” to the following questions:
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  • 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.

  • IF PATIENT IS A MINOR

    Please answer the following questions so that we may be able to provide the best resources for your needs. We understand that there are often challenges and we are here to help. Please choose “YES” or “NO” to the following questions:
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  • CONTROLLED SUBSTANCE MEDICATION AGREEMENT

  • 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.

  • I agree to take my medication as prescribed and not alter the way I take my medication without consulting my prescriber.*
  • I agree to inform my Astra Behavioral Health, LLC provider of all medications prescribed by other providers, and all non-prescription medications I am taking during my Initial Evaluation.*
  • I agree not to obtain medications from another physician, nurse practitioner, hospital, dentist, pharmacy, or any other sources without discussing with my prescriber beforehand.*
  • I agree that I have been provided with information regarding the potential side effects of the specific controlled substance prescribed to me, and agree to notify my provider if I experience one or more symptoms while taking the medication.*
  • I agree to obtain lab work as ordered by my Astra Behavioral Health, LLC provider to include labs related to my treatment. I agree to seek medical clearance to allow controlled substance medication management, should there be any abnormal lab results.*
  • I agree that I will not operate a motor vehicle, or heavy machinery, during either my first days of taking the prescribed controlled substance medication, or after a dosage increase to ensure my tolerance of the medication does not cause side effects of drowsiness or lethargy.*
  • I agree to not sell, share, or give my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.*
  • I have been informed that my prescription must be protected from theft or unauthorized use. I have been informed that if I report my medication has been lost or stolen, my prescriber will not be expected to provide a replacement. If there has been a theft of my medication, I will report this to authorities and bring a copy of the police report to my next appointment.*
  • I agree to not conduct any illegal or disruptive activities in or around property owned/operated by Astra Behavioral Health LLC and to treat all office staff with respect. I agree that should such behavior occur, including rude or disrespectful comments; I will be terminated from treatment without recourse for appeal and the appropriate authorities will be notified.*
  • I agree to abstain from benzodiazepine medications, alcohol, opiates, stimulants, and other addictive substances while being prescribed buprenorphine, or any controlled substances, and I understand that my prescriber may terminate my treatment if I violate this term of the treatment agreement.*
  • I agree that I will be open and honest with my Astra Behavioral Health, LLC provider, and treatment team and will inform my provider and therapist about cravings or unhealthy situations in which I am involved, specifically regarding any misuse of my prescribed medications and/or relapse, that has occurred before a drug screening confirms it.*
  • I agree to comply with urine drug screening and pill counts at every appointment, thereby, documenting the proper use of any medication. If alcohol abuse is suspected, a breathalyzer or blood alcohol level may be ordered. Unannounced urine or serum toxicology specimens may be requested and my cooperation is required.*
  • I agree to comply with random drug testing required within 24 hours of my provider’s request. I understand that if this office is unable to reach me for notification of a random screening, I may be discharged without further notice. Therefore, I agree to immediately notify this office of any change of address and/or phone number.*
  • I agree that I will be subject to drug screens. I understand that when performing a urine drug screen, a staff member may witness me if suspected of altering my urine sample, or misusing my medication. I also understand that attempts to alter my urine or providing a sample other than my own may result in termination from treatment without recourse for appeal.*
  • I understand that Astra Behavioral Health, LLC will use the Kentucky All Schedule Prescription Electronic Reporting (KASPER) system to monitor my prescription history on a regular basis.*
  • I have been given a copy of clinic procedures, including hours of operation, the clinic phone number, and responsibilities to me as a recipient of controlled substance medications and treatment services at Astra Behavioral Health, LLC.*
  • I understand that if I violate any of the above conditions, my prescription for controlled medications may be terminated. If the violation involves obtaining these medications from another individual, or the concomitant use of non-prescription illicit drugs, I may also be reported to other providers, pharmacies, medical facilities and appropriate authorities.*

  • 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 understand that combining buprenorphine with benzodiazepine medications (Valium, Klonopin, Ativan, Xanax, Librium, Serax, etc.), alcohol, and other sedating drugs have been associated with severe adverse side effects, including death.

  • 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.

  • TODAY'S DATE*
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  • POLICY ACKNOWLEDGEMENTS AND CONSENTS

    Page 4 of 4
  • DATE OF BIRTH*
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  • 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.

     

  • TODAYS DATE*
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