Registration Form

Step 1 of 12

Patient Information

Today's Date

MM slash DD slash YYYY

Patient Name*

First Name Middle Initial Last Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mobile/Cell Phone*

Home Phone

Work Phone

Email*

Date of Birth*

MM slash DD slash YYYY

Sex*

Male

Female

Race*

White

Black

Asian

Other

Identified Gender

Are you a new or existing patient?*

New

Existing

Ethnicity

Preferred Language

Emergency Contact

Emergency Contact*

First Last

Emergency Contact Phone*

Emergency Contact Relationship*

Responsible Party*

If patient is a minor or has a legal representative or guardian, additional information is needed.

Patient

Guardian or Legal Representative

Responsible Party Info

Responsible Party*

First Last

Responsible Party Address

(if different from patient)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Responsible Party Phone*

Responsible Party Email*

Insurance Information

Primary Insurance*

Primary Insurance Policyholder Name*

First Last

Primary Insurance Policyholder Relationship to Patient*

Primary Insurance Policyholder Date of Birth*

MM slash DD slash YYYY

Primary Insurance Policy Number*

Primary Insurance Policy Group Number*

Do you have another insurance policy?*

Yes

Secondary Insurance*

Secondary Insurance Policyholder Name*

First Last

Secondary Insurance Policyholder Relationship to Patient*

Secondary Insurance Policyholder Date of Birth*

MM slash DD slash YYYY

Secondary Insurance Policy Number*

Secondary Insurance Policy Group Number*

Electronic Signature*

By typing or signing your name into the signature boxes on these forms you are signing these agreements electronically. You agree that your electronic signature is equivalent to your manual signature on these agreements as per UNIFORM ELECTRONIC TRANSACTIONS ACT (1999) of the United States.

I agree

Phone Messages*

Can we leave a text or message at the phone number provided with family member/s or on the voicemail for appointment reminders or other information?

Yes

Patient Signature*

Responsible Party Signature*

Today's Date

MM slash DD slash YYYY

Assignment/Release/Consent to Treatment

I authorize and request treatment/s from RAVI KANT, M.D. and/or his associates to perform routine diagnostic procedures and to provide medical treatment as is medically necessary in his/their professional judgment.

I hereby authorize release of protected health information, including mental health and/or substance abuse (drug and alcohol), necessary to file a claim with my insurance carrier and assign benefits otherwise payable to me to RAVI KANT, M.D. PC as indicated on the insurance claim form. I understand that this facility and its providers are mandated reporters of any and all suspected or witnessed child abuse and/or neglect. (Section 6383 (b) of Title 23 of the Pennsylvania Consolidated Statutes/Act of July 1, 2015, P.L. 94, No. 15). I also understand that I am financially responsible for any balance not covered by my insurance carrier(s) (including but not limited to deductibles and/or co-payments) and agree to pay the full charges if payment is/are denied by my insurance carrier(s) for any reason or if no insurance coverage exists at the time of services. It is my responsibility to update any changes in insurance. I understand it is mandatory to notify the health care provider of any other party who may be responsible for payments (section 1128 B, Social Security Act and 31 U.S.C. 3801- 3812 provides penalties for withholding this information). Medicare regulations apply. I have received, read and agree with the billing and other office policies.

With my consent, Ravi Kant, M.D., his associates, and office staff can call my home and leave messages on an answering machine or with a person, text, or e-mail me regarding appointments and contact the designated emergency contact person if needed. I may revoke my consent in writing except to the extent that the practice has already acted upon in reliance upon my prior consent. If I do not sign this consent, Ravi Kant, M.D. and his associates may decline to provide services to me. I agree with the above.

All the information provided in this Registration-Assignment/Release/Consent to Treatment is true and current.

Notice of Health Information Practices - Ravi Kant, MD, P.C.

(Copy is available and posted in office for your review or available for download at www.drkant.com)
I have read and understood the above Notice of Health Information Practices. I recognize that this is a federal mandate that this facility must comply with.

Notice of Patient Rights and Responsibilities - Ravi Kant, MD, P.C.

(Copy is available and posted in office for your review or available for download at www.drkant.com)
I have read and understood the Patient Rights and Responsibilities provided at the office.

Notice of Grievance Procedure - Ravi Kant, MD, P.C.

(Copy is available and posted in office for your review or available for download at www.drkant.com)
I have read and understood the Grievance Procedure provided at the office.

Patient Signature*

Responsible Party Signature*

Today's Date

MM slash DD slash YYYY

Office Policies

Insurance Coverage:

Due to frequent changes in insurance coverage (benefits, exclusions, deductibles and/or prescription coverage, etc.), we cannot inform or advise you about your benefits. In some insurance policies, certain diagnoses may be excluded, such as ADHD, Autism, Mental Retardation and related conditions. We do not routinely do the paperwork for non-formulary medicines not covered by your insurance company. You are responsible for keeping track of number of visits allowed in your plan and how many visits you have used with your therapist and prescriber. You will be charged for additional visits. If you do not have insurance coverage, you are responsible for the full charges. Please inquire in advance about our charges if you do not have insurance.

Payments:

It is our policy to collect all co-payments and/or deductibles at the time of service unless arrangements are made ahead of time. We accept checks, cash, and debit or credit cards (Visa, MasterCard American Express or Discover).

A service charge of $10.00 plus interest (1.5%/month) may be added to any outstanding balance over 30 days past due. Also, all delinquent accounts (over 90 days past due) may be turned over to a collection agency. An additional $40.00 as a handling fee and the costs of collection (including attorneys’ fees and costs) will be added to the total amount due.

Cancellation/No Show Policy:

We understand that it is not always possible to keep a scheduled appointment or give 24 hours notice of cancellation. If a pattern of same day cancellation or “No Shows” develop, we reserve the right to bill you $50.00 fee for the missed appointment time. Your insurance company is not responsible for this charge. Prescriptions may not be called in for No Show or Canceled appointments. Additionally, if there are frequent No Show for appointments or non-compliance with treatments, you may be discharged from the practice.

Lost Prescription Fee:

A service fee of $20.00 will be charged to replace lost scripts. Scripts will need to be picked up from the office after payment of the fee.

Returned checks:

Fee of $40.00 will be charged for checks returned for any reason.

**Fees may be changed without notice.

I have read and agree to be legally bound by the terms of these office policies including the financial responsibility provisions hereof. I understand that I am financially responsible for any amounts not covered or paid by my insurance carrier and that I am responsible for providing current insurance information and inform the office of any address and/or insurance changes.

Patient Signature*

Responsible Party Signature*

Today's Date

MM slash DD slash YYYY

Authorization For Release Of Protected Health Information

From Ravi Kant, MD, P.C.

Please release my medical information to the following:*

Please note that if the patient is 14 year or older a signed release by the patient is required to share information with the patient’s parents or legal guardians.

PCP

Family Member

Therapist

Other

None

Other party to disclose information to:*

The purpose or need for this disclosure is:*

Coordination of Care

Disability Application

Other

The purpose or need for this disclosure is:*

Release to*

Name of provider, facility, or family member where records are being released to.

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Would you like to share your medical information with anyone else?*

Yes

Please release my medical information to the following:*

PCP

Family Member

Therapist

Other

Other party to disclose information to:*

Release to*

Name of provider, facility, or family member where records are being released to.

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Would you like to share your medical information with anyone else?*

Yes

Please release my medical information to the following:*

PCP

Family Member

Therapist

Other

Other party to disclose information to:*

Release to*

Name of provider, facility, or family member where records are being released to.

First Last

Address*

Street Address Address Line 2 City State ZIP Code

I authorize the entities named above to share the health related information related to my care.*

Initial here:

Today's Date

MM slash DD slash YYYY

Records To Be Released*

I understand that the specific types of records to be released (identify all records or all that apply) are:

All records including Psychiatric/psychological evaluation

Laboratory reports & tests

Physician notes only

Insurance claims and payments only (including Medicare and Medicaid)

Other

Specify other records:*

**Mental or behavioral health, substance abuse, and HIV-related information contained in the parts of the records indicated above will be released through this authorization unless otherwise indicated.**

DO NOT RELEASE:

Mental/Behavioral Health (Psychiatric)

HIV-Related

Substance Abuse (Drug and Alcohol)

Is the patient is 14 years or older?*

Yes

Patient Signature*

I consent to and authorize to disclose my protected health information relating to my identity, diagnoses, prognosis, and/or treatment. These records may include information related to medical conditions, tests, mental or behavioral health, substance abuse (drug and alcohol), and HIV-related. These records are called protected health information and are protected by federal and/or state law.

I understand that this authorization is revocable upon my written request and that this consent will remain in force unless revocation from the patient or legal guardian is received. I also understand that any revocation of this authorization must be in writing and sent or delivered to my health care provider’s office. I also understand that my decision to revoke this authorization may result in my insurance company not being able to pay for my medical care and I will be liable for payment for the services rendered.

Minor Patient Signature*

Please note that if the patient is 14 year or older a signed release by the patient is required to share information with the patient’s parents or legal guardians.

Responsible Party Signature*

Today's Date

MM slash DD slash YYYY

Consent To Discuss Protected Health Information Via Electronic Communication

Patient Signature*

By signing below, I permit NeuroPsychiatry Center to communicate protected health information for the above patient via e-mail at the e-mail address provided on this form.

Responsible Party Signature*

Today's Date

MM slash DD slash YYYY

E-MAIL RISKS AND YOUR RESPONSIBILITY:

You and your provider/s at NeuroPsychiatry Center (NPC) and its employees and staff have agreed to correspond using e-mail. These e-mails may contain personal protected health information including, mental health issues. You need to be aware of the risks and your responsibilities.

As the internet is not secure or private, unauthorized people may be able to intercept, read, and possibly modify e-mail/s you send or receive from NPC. You must protect your e-mail account and password against unauthorized use. Hackers can get access to your account.
Viruses can be spread via e-mail and some may cause e-mail messages to be sent to unintended people.
E-mails can be copied, printed, and forwarded by recipients; be careful with whom you send or share e-mails.

CONDITIONS FOR THE USE OF E-MAIL:

By consenting to the use of e-mail with NPC you agree that:

NPC may forward e-mails, as appropriate, for diagnosis, treatment, billing, and other related reasons. Employees and medical staff other than the intended recipient may have access to your e-mails.
Although NPC will try to read and respond to your e-mail, we may not read your e-mail immediately. If you do not receive a response within a reasonable time, it is your responsibility to contact us to follow up.
You should carefully consider the use of e-mail for the communicating sensitive medical medical and personal information.
E-mail messages should be short, clear, and concise.
NPC reserves the right to save your e-mail including the information contained there in the medical records.
You agree not to abuse the right to communicate with your physician's office and your communications will be professional in content.
E-mail access to staff is being provided as a convenience to our patients and NPC has the right to restrict your ability to communicate with us via e-mail at any time for any reason, including cases where NPC reasonably believes that it is not in your best interest to continue to seek advice via e-mail and an in person appointment is needed or that e-mail is being used excessively in lieu of in person care.

INSTRUCTIONS:

You should immediately inform the staff at NPC of any changes in your e-mail address.
E-mail should be used only for non-sensitive and non-urgent issues such as prescriptions, scheduling, general questions or advice. E-mail is not a substitute for psychotherapy or medication management appointments.
Please put the patients name and date of birth in the body of the e-mail for proper identification.
If you wish to withdraw your consent to communicate via e-mail, you must inform NPC in writing.

ACKNOWLEDGEMENT AND AGREEMENT

NeuroPsychiatry Center will use reasonable means to protect the privacy of the patient’s health information. However because of the risks outlined above, NPC cannot guarantee e-mails will be confidential. Also NPC will not be liable in an event that you or anyone else inappropriately uses or accesses your e-mail. NPC will not be liable for improper disclosure of your health information that is not caused by our intentional misconduct.

NPC is not responsible for e-mail messages that are lost due to technical failure during composition, transmission and/or storage. NPC may impose restrictions to communicate with me by e-mail. I have read and understand the information above, and had any questions answered to my satisfaction. I have received the copy of this consent form. I agree to the guidelines for e-mail communication. I understand that this consent is valid until such time as I revoke the consent outlined above, except to the extent that a staff has already acted in reliance upon this authorization.

Patient Signature*

Responsible Party Signature*

Today's Date

MM slash DD slash YYYY

Would you like to sign up to receive updates and important announcements?*

Yes please!

No thanks.

DO NOT SEND E-MAIL FOR EMERGENCIES
Go to the nearest hospital, call 911, or contact your county’s emergency crisis number.

We will not read e-mails on weekends, holidays, or when on vacation.

Prescription Refill Policies And Procedures

In order to make the prescribing medication and requesting temporary refills process efficient, we will follow the procedures listed below. Patients or a parent/legal guardian should initial and sign below.

Check which medications need refilled before coming to your appointment. It is YOUR responsibility to get your medications refilled during your visit. Schedule your next visit at least one week prior to running out of your current refill(s).
If you require a medication refill in-between scheduled appointments, it is YOUR responsibility to request it from our website - www.drkant.com and fill in the “Medication Refill Request” online. Refill requests are NOT accepted via phone. We need at least 72 hours notice (excluding weekends or holidays) to respond to your request. Please note that we do NOT accept medication refill requests from pharmacies.

I understand the above:*

Initial here

Today's Date

MM slash DD slash YYYY

Regular office visits are required for monitoring and prescribing medications as determined by your provider. Medications will not be called in without required office visits.

I understand the above:*

Initial here

Today's Date

MM slash DD slash YYYY

Blood work is needed for some medications to assess the safety and effectiveness. For patients who do not get the blood work done in a timely fashion, we will refuse to fill their prescriptions.

I understand the above:*

Initial here

Today's Date

MM slash DD slash YYYY

If prescribed a controlled substance as identified by the DEA, per office policy, patients must be seen at least every 4-8 weeks, at the discretion of the provider. Refills for controlled substances will only be provided during appointments. Random urine screens may be requested to assess the use of narcotics or abuse of illicit drugs.

I understand the above:*

Initial here

Today's Date

MM slash DD slash YYYY

Patient Signature*

I have read the Prescription Refills Policies and Procedures and by initialing above and signing below, I agree to abide by them in full and have been given a copy if requested.

Responsible Party Signature*

I have read the Prescription Refills Policies and Procedures and by initialing above and signing below, I agree to abide by them in full and have been given a copy if requested.

Today's Date

MM slash DD slash YYYY

E-Prescribing Medication History Consent

I understand that NeuroPsychiatry Center utilizes e-prescribing. I understand that e-prescribing allows the practice to send prescriptions electronically to pharmacies, eliminating the need for prescribing via paper, phone, or fax. E-Prescribing is fast, convenient, legible, secure, cost-effective and safe. In some cases, it also allows the health care provider to access critically important information about patient’s current and past medications from pharmacy benefit managers and community pharmacies. This helps to alert the provider to other potential medication interactions or if patient is getting same or similar medications from multiple providers.

I have been given an opportunity to ask questions about the e-prescribing process and have had those questions answered to my satisfaction. I hereby consent to the practice requesting and using my medication history from other health care providers, pharmacies, or third-party pharmacy benefit payers for treatment purposes.

Patient Signature*

Responsible Party Signature*

Today's Date

MM slash DD slash YYYY

Personal Crisis Plan

My Triggers:*

Thoughts/Inside Warnings:*

Outside Warning Signs:*

When I Notice My Triggers I Will:*

When Others Notice I’m Upset I’d Like Them To:*

Things That Help Me Stay Better Now:*

Things That Help Me Stay Well on a Regular Basis:*

Things That Make Me Feel Worse:*

If I’m feeling unsafe, I will go to the ER of local hospital, call Suicide Hotline 1-800-273-8255, or call my county’s crisis number.

Patient Signature*

Responsible Party Signature*

I certify that this data is true, correct & accurate. I understand that payment of this claim will be from federal & state funds. Any false claims, documents, or concealment of material facts may be prosecuted under applicable laws. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.

Today's Date

MM slash DD slash YYYY

Supporting Documentation

Driver's License

Please scan and upload front and back of driver's license.

Drop files here or

Max. file size: 1,000 MB.

Insurance Cards

Please scan and upload front and back of all insurance cards.

Drop files here or

Max. file size: 1,000 MB.

Credit Card Information

Please complete all fields. You may cancel this authorization at any time by contacting us in writing. This authorization will remain in effect until cancelled.

NeuroPsychiatry Center - Ravi Kant, MD, P.C.
300 Old Pond Road, Suite 201, Bridgeville, PA 15017
Tel. # 412-220-7323
Fax # 412-220-7325

Card Type:*

MasterCard

VISA

Discover

AMEX

Other

Cardholder Name:*

(as shown on card)

First Last

Last 4 Digits of Credit Card*

Please call the office to provide your full credit card number.

Expiration Date (mm/yy):*

(Enter in the mm/yy format)

Cardholder ZIP Code:*

(from credit card billing address)

CVV:*

(3 digits on the back of the card)

I authorize NeuroPsychiatry Center to charge my credit card listed above for services provided. This can include self-pay fees, co-payments, deductible, and other charges such as no-show fees, and services not covered under my insurance. I understand my credit card will not be charged more than $300 at one time. I understand that my information will be saved on file for future transactions on my account. I am responsible for keeping this information updated in a timely manner.

This authorization will apply to any credit card updates in the future. I am aware that NeuroPsychiatry Center will be unable to notify me before processing this card on file and that my card may be charged at any time at the discretion of NeuroPsychiatry Center for the reasons listed above. These circumstances DO NOT apply to medical assistance recipients.

Patient/Guardian Signature*

Date

MM slash DD slash YYYY

{all_fields}

After you click "Submit" you will be redirected to our Psychiatric Intake Form on another website.

This field is for validation purposes and should be left unchanged.

Registration Form