Initial Intake Hornell Office

Milestone Psychiatric & Psychological Services, P.C.
(Comprehensive Psychiatric & Psychological Services)

 
 

PSYCHIATRY:
Raja Rao, MD
NURSE PRACTITIONER:
Michelle S. Bennett, NPP in psychiatry
PSYCHOLOGY:
Robert J. Maiden, PhD
Andrea Burch, Psy.D.
PSYCHOLOGY:
Lynn O’Connell, PsyD
Caprice Murphy LCSW-R
Michele Lowry, PsyD
       
1151 Pittsford Victor Rd., Ste 103
Pittsford, NY 14534
(P) 585-593-9815
(F) 716-372-9497
15 Pleasant St
Hornell, NY 14843
(P) 607-324-9240
(F) 607-324-9744
3460 Riverside Drive, PO Box 55
Wellsville, NY 14895
(P) 585-593-1859
(F)585-593-5463

 
 

PLEASE PRINT CLEARLY

Dr. Rao has agreed to see you for an initial evaluation. An initial evaluation does not guarantee that you will be accepted as a patient. Dr. Rao will decide how to proceed after this consultation, and based on his findings, a treatment plan will be developed. This includes, but is not limited to; the acceptance as a new patient, referral to another provider within or out of Milestone.

 
 
Client:

Your First Name

 

Your Last Name

 

Your Middle Initial

 

Your Email

 

Your Date of Birth

 

Sex Male Female

 

Address

 

Phone

 

Can we leave a message? Yes No

 

Employer

 

Student Not Employed

 

Primary Care Physician

 

Primary Care Physician Phone

 

Pharmacy Name

 

Pharmacy Phone

 

Emergency Contact

 

Emergency Phone

 

Relationship to Patient

 

Referring Doctor/Source

 

Insurance Name

 

Insurance Member ID

 

Subscriber

 

Subscriber DOB

 

Relationship to Patient

 
*** please note if there is additional insurance coverage ***
 

Presenting Problem:
What is the main concern that prompted you to make this appointment?

 

Psychiatric and Psychological History:
Provide all past mental health and substance abuse treatment, including outpatient and inpatient.

 

Medication History:
List all current psychiatric medications; Drug, Dose, Frequency, Prescribing Physician:

 

Past Medications:

 

Other Medications:
List current medications other than psychiatric; Drug, Dose, Frequency, Prescribing Physician:

 

Non-Prescription Medications:
List any non-prescription medications:

 

Medical and Surgical History—Past/Present:

 

Social History (If a child, marital status of parents): (required) Single Married Widowed Divorced Separated Partnered
Name (required)

 

Children (if a child, please list siblings):
List Name, Age, Location, and Custody (Joint/ Single, etc):

 

Pertaining to children who will be seen:

Lawyer

 

Lawyer's Phone Number

 

Law Guardian

 

Law Guardian's Phone Number

 

School Counselor

 

School Counselor Phone Number

 

Financial Policy:

 

We are dedicated to providing the best possible care for you, and we want you to completely understand our payment policies.

 

1. Insurance: We participate in most insurance plans, including Medicare. If you are insured by a plan we do business with but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage.

 

2. Co-payments and Deductibles: All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. For your convenience we accept MasterCard and Visa. You will be billed a $10 handling fee for not paying your co-pay at the time of service unless other arraignments have been made.

 

3. Non-covered Services: Be aware that some and perhaps all of your services you receive may be non-covered or not reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of your visit.

 

4. Proof of Insurance: All patients must complete out patient registration form before being seen. We must obtain a copy of your current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in time to meet your insurance company claim filing limit, you will be responsible for the balance of the claim.

 

5. Claims Submission: We will submit your claims and assist you in any way we reasonably can to help you get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

 

6. Coverage Changes: If your insurance changes, please notify us so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.

 

7. Non-payment: If your account is over 30 days past due, you will receive a letter stating that you have 30 days to pay your account in full. Partial payment will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternate medical care.

 

8. NO SHOW Fees: The number of patients requiring services dictates the use of time responsibly. Please be advised of the institution of a no show fee for failure to come to a scheduled appointment without at least 24 hours prior notice with the exception of an emergency. This fee cannot be billed to an insurance company and is due prior to your next appointment. We reserve the right to not reschedule future appointments.

 

PsyD/ PhD $40.00 (16-37 min)/$80.00 (38-or more min)

MD/ FNP $60.00

 

Professional Fees

The fee for an initial visit is $230.00. Subsequent 16-37 minute session $103.00, 37-50 minute sessions are $166.00, and 53-60 minute session is $269.00, and medication management visits are $110.00. You may be eligible for a sliding-scale self-pay rate, please inquire with the receptionist.

 

Professional services that you may request and/or require, including written reports, consultation with other professionals (with your informed consent), and telephone, fax, and/or e-mail communications which become excessive and beyond the scope of reasonable services, will be billed at $161.25/hour accrued in 15 minute intervals.

 

If you become involved in legal proceedings that require participation, you will be expected to pay for all professional time, including preparation, travel, and attendance at any legal proceeding. Due to the complexity of legal proceedings and time away from client hours, the hourly rate is $250.00, accrued in 15 minute intervals.

 

Occasionally, it may be advisable to administer self-report rating scales and/or other social-emotional and psychological measures. You should be aware that your insurance company may not cover the cost for the administration and scoring of these assessment measures. In addition, psycho educational assessments may not be covered by your insurance company. Rates for these types of psychological testing are generally $174.00 per unit. Specifics and financial arrangements should be discussed prior to service.

 

Our practice is committed to providing the best treatment to our patients. Our fees are representative of the usual and customary charges for our area. Let us know if you have any questions or concerns.

 

I have read and understand the Financial Policy and Professional Fees and agree to abide by these guidelines:

 

Signature of patient (or responsible party, if minor)

 

Date

 

Prescription Refill Policy

 

When you have a prescription that needs to be refilled, please do the following:

 

1. Please call the office at least 7 -10 days in advance. Failure to do so may result in you not getting your prescriptions filled in a timely manner.

 

ALL prescriptions need approval from Dr Rao, Kim Peckham / Michelle Bennett before they can be obtained.

 

2. Please have all applicable information ready for the receptionist when calling (prescription name, pharmacy, etc).

 

Signature of patient (or responsible party, if minor)

 

Date

 

Informed Consent for Treatment

 

Clinical records are kept under the strictest rules of confidentiality, which means that information about your treatment will not be releases to any outside agency or individual without your written permission. Please be advised, however, that rules of confidentiality will be broken under certain circumstances as described in the NOTICE OF PRIVACY PRACTICES below. Please do not hesitate to ask questions.

 

Entering mental health treatment is a courageous step. You should know that sometimes symptoms become worse before they become better, though this should subside as the work of treatment progresses. You may be asked to participate in activities and tasks outside the sessions held here. While you have the right to refuse any therapeutic technique, we must be able to discuss your thoughts and feelings about treatment. You will be involved in the process of designating and implementing, and the periodic review, of your treatment plan. You have the right to be informed of your mental health diagnosis after the mental health assessment is completed, and the purpose of any prescribed medication and potential side effects. You also have the right to withdraw consent and terminate services at any time. If you have any questions about the nature if your treatment, talk directly to the doctor you are seeing as soon as the question arises.

 

I authorize Milestone PPS, PC to release given info to my listed insurance company, information from my records relating to the identity, diagnosis, and treatment for the purposes or needs of payment.

 

Signature of patient (or responsible party, if minor)

 

Date

 

HIPAA

 

I have reviewed the HIPAA privacy statement.

 

Signature of patient (or responsible party, if minor)

 

Date

 

Call Reminder Notification:

 

Please be advised that Milestone utilizes a call reminder system as a courtesy to patients. Please DO NOT depend on these calls, as there is the possibility of system malfunction. Milestone is not responsible for missed appointments due to the call reminders not being received, or malfunctioning. Thank you.

 
Please confirm that you are not a robot: