Telemedicine Consent Form The purpose of this form is to obtain consent from the patient to participate in “telemedicine appointments”. Audio or video of appointments will not be recorded or stored. ACCEPTANCE OF TERMSI agree to have access to a desktop, laptop, tablet, or mobile device and a stable internet connection in order to have an efficient appointment.I understand the physician, Dr. Uddin, will maintain confidentiality as is the case of an in-person appointment in an one setting. I understand that all laws that protect my health information apply to telemedicine as well.I authorize Dr. Asif Uddin to use the information acquired in my diagnosis and treatment.I am entitled to withdraw this consent at any time.By checking this box, I have read and agree to the terms above.Clinic Policies and Financial Agreement Asif Uddin, MD (“Dr. Uddin”) provides direct payment fee-for-service consultations and treatments at and through KC Psychiatrist, LLC (the “Practice”). Please make note of the following policies: WE DO NOT ACCEPT INSURANCE. A new patient psychiatric evaluation fee is $400.00. A $200.00 NONREFUNDABLE deposit is required at the time of scheduling. A comprehensive medical and psychiatric evaluation is $500.00. Dr. Uddin will provide primary care and psychiatric services. A $200.00 NONREFUNDABLE deposit is required at the time of scheduling. A medical marijuana evaluation and renewal fee is $150.00. This fee is nonrefundable. All follow up appointments are $200.00, due at the time of the scheduled appointment. New patient paperwork and release of information must be completed AT LEAST 1 week (7 days) PRIOR to the scheduled appointment. FAILURE TO DO SO may result in cancellation of the appointment and forfeiture of $200.00 deposit. Paperwork of any sort (FMLA, short term disability, ADA, etc.) to filled out by Dr. Uddin will incur a charge of $50.00 due prior to completion. Letters written to any entity or organization will be be charged at $25.00. Payment may be made via credit, debit, HSA account, or in person. We require an active form of payment on file and reserve the right to charge the card for any outstanding balance. We do not issue refunds for any rendered services. By checking this box, I have read and agree to the terms above.HIPAA Disclosure - Confidentiality Agreement Information about one's health, health care, and payment for health care is called Protected Health Information (PHI). We safeguard your PHI and provide you this notice summarizing our privacy practices.It describes how, when, and why your medical information may be used and disclosed. We ask that you please review it carefully. *Note, our privacy practices and the terms of this notice may change at any time. If we revise the notice, at your request, we can provide you with an updated Notice of Privacy Practices. You may ask for a copy either electronically, by mail, or in person. We may use and disclose your Protected Health Information as follows without your permission: For treatment purposes.We may disclose your health information to doctors, nurses, and others who provide your health care. For example, the information may be shared with people performing lab work or x-rays. To secure payment.We may disclose your health information in order to collect payment for health care services rendered or to be rendered. For health care operations.We may use or disclose your health information to contact you to remind you of your appointment or to call you by name in the waiting room when your doctor is ready to see you. When required by law.We may be required to disclose your Protected Health Information to law enforcement offers, courts, or government agencies. For example, we may have to report abuse, neglect, or certain physical injuries. For public health activities.We may be required to report your health information to government agencies to prevent or control disease or injury.We also may have to report work-related illnesses and injuries to your employer so that your workplace may be monitored for safety. For health oversight activities.We may be required to disclose your health information to government agencies so that they can monitor or license health care providers such as doctors and nurses. To avert a threat to health or safety.In order to avoid a serious threat to health or safety, we may disclose your health information to law enforcement officers or other persons who might prevent or lessen that threat. Patient Rights:You may request a copy of your Protected Health Information, in most cases. You may not view information collected for use in legal or government action, or information which you cannot access by law. As we use and maintain your PHI electronically, you may request it in electronic format. You may ask us to limit how we use or disclose your information. We cannot limit uses or disclosures that are required by law. To request confidential communication methods. You may ask that we contact you at a certain address or in a certain way. NOTE: Any of the patient request, may be denied at the discretion of the practice. If you have questions about this Notice or about our privacy practices, please contact our office. Effective Date 7/1/20By checking this box, I have read and agree to the terms above.New Patient Intake Form Please complete the following intake form. Note: Red asterisks indicate required fields.Gender *MaleFemaleDate of Birth *Social Security Number *0 / 11Street Address *City *State/Province *ZIP / Postal Code *Emergency Contact (Name, relationship, and phone number)Reason for appointmentCurrent/Most Recent Psychiatric Provider (Facility/Provider)Past Psychiatric DiagnosesPast Psychiatric MedicationsPrevious psychiatric admissions? *YesNoPlease Explain:Current medications (Please include both medical and psychiatric)Medication AllergiesPreferred PharmacyPast Medical HistoryPast Surgical HistoryFamily History (medical/psychiatric)Substance Abuse history (check all that apply) *TobaccoAlcoholDrugsN/APlease ExplainGovernment Photo Identification *Driver's License/State IDPassportFederal IDREQUIRED TO PRESCRIBE MEDICATIONSUpload Government Photo Identification *Choose FileNo file chosenDelete uploaded fileHow did you find us? (check all that apply) *Psychologytoday.comYelpGoogleReferralHealthGradesZocDocOtherIf other please explainPatient Health Questionnaire (PHQ-9) Source: Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRE-MED-PHQ). The PHQ was developed by Drs. Robert L Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues.Feeling down, depressed, irritable or hopeless?Not at allSeveral daysMore than half the daysNearly every dayLittle interest or pleasure in doing things?Not at allSeveral daysMore than half the daysNearly every dayTrouble falling asleep, staying asleep or sleeping too much?Not at allSeveral daysMore than half the daysNearly every dayPoor appetite, weight loss, or overeating?Not at allSeveral daysMore than half the daysNearly every dayFeeling tired or having little energy?Not at allSeveral daysMore than half the daysNearly every dayFeeling bad about yourself – or feeling that you are a failure, or that you have let yourself or your family down?Not at allSeveral daysMore than half the daysNearly every dayTrouble concentrating on things, such as reading the newspaper or watching television.Not at allSeveral daysMore than half the daysNearly every dayMoving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you were moving around a lot more than usual?Not at allSeveral daysMore than half the daysNearly every dayThoughts that you would be better off dead or of hurting yourself in some way?Not at allSeveral daysMore than half the daysNearly every dayIf you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?Not difficult at allSomewhat difficultVery difficultExtremely difficultGeneral Anxiety Disorder (GAD-7) Over the last two weeks, have you been bothered by the following problems?Not being able to stop or control worryingNot at allSeveral daysMore than half the daysNearly every dayWorrying too much about different thingsNot at allSeveral daysMore than half the daysNearly every dayFeeling nervous, anxious or on edgeNot at allSeveral daysMore than half the daysNearly every dayTrouble relaxingNot at allSeveral daysMore than half the daysNearly every dayBeing so restless that it is hard to sit stillNot at allSeveral daysMore than half the daysNearly every dayBecoming easily annoyed or irritableNot at allSeveral daysMore than half the daysNearly every dayFeeling afraid, as if something awful might happenNot at allSeveral daysMore than half the daysNearly every dayIf you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?Not difficult at allSomewhat difficultVery difficultExtremely difficult Submit Form
