My Psychiatrist Intake form

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Your Name* This field is required.
First Name
Middle Name
Last Name
Suffix
2
Your Gender and Date of Birth* This field is required.
Male
Female
Others
Gender
Date of Birth
3
Contact Information
Street Address
City
State
Postal Code
Mobile number
email address
Office number
Home Phone no
4
How did you hear about us?
Insurance Company
Referral from Health care provider
Google
From Friends or Family
Facebook
Instagram
5
Policy Holder/Guarantor
Self (go to next page)
Others
Who is Policy Holder
Name of Policy Holder (if not self)
Date of Birth of policy holder
Policy Holder SSN (only for Medicare patients)
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Billing address* This field is required.
Same as home address
Other address (Please enter billing address in next section)
7
Billing Address
Street Address
Apartment/Suite etc
City
State
Postal Code
8
Detail Payor information
Self Pay
Aetna
Cigna
United Health Care
Carefirst
Anthem
Medicare
Others
Payor Information
Policy Holder Name
Policy Number
9
Emergency Contact
Emergency Contact Name
Relationship
Mobile number
10
Primacy Physician info
Name
Phone number
11
Legal Guardian info (skip this if you are 18 or above)
Legal Gurdain Name
Relationship
Phone number
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Insurance card Front* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Insurance card Back* This field is required.
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Select files to upload
Max. file size: 10.6MB
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Driver License Front* This field is required.
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Max. file size: 10.6MB
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* This field is required.
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* This field is required.
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* This field is required.
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By signing below I agree to give "consent to the treatment" and agree with My Psychiatrist cancellation, medication refill and financial policy as stated above. I also acknowledged to received and reviewed My Psychiatrists HIPPA policy:* This field is required.
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PSYCHIATRIC/ MEDICAL and/or ALCOHOL/DRUG ABUSE RECORDS

This authorization may be used to permit a covered entity (as such term is defined by HIPAA and applicable Virginia law) to use or disclose an individual’s protected health information. Individuals completing this form should read the form in its entirety before signing and complete all the sections that apply to their decisions relating to the use or disclosure of their protected health information.

The individual signing this form agrees and acknowledges as follows:

(i) Voluntary Authorization: This authorization is voluntary. Treatment, payment, enrollment or eligibility for benefits (as applicable) will not be conditioned upon my signing of this authorization form.

(ii) Effective Time Period: This authorization shall be in effect until the earlier of two (2) years after the death of the patient for whom this authorization is made.

(iii) Right to Revoke: I understand that I have the right to revoke this authorization at any time by writing to the health care provider or health care entity listed above. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

(iv) Special Information: This authorization may include disclosure of information relating to DRUG, ALCOHOL and SUBSTANCE ABUSE, MENTAL HEALTH INFORMATION, except psychotherapy notes, CONFIDENTIAL HIV/AIDS-RELATED INFORMATION, and GENETIC INFORMATION only if I place my initials on the appropriate lines above. In the event the health information described above includes any of these types of information, and I initial the corresponding lines in the box above, I specifically authorize release of such information to the person or entity indicated herein.

(v) Signature Authorization: I have read this form and agree to the uses and disclosure of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws.
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Following is the List of individuals I authorized to release my medical informationUse this form to allow us to disclose your medical information to your family or other physicians.
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By signing below I agree Authorized My Psychiatrist to release my medical record to the person listed above.:
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