Intake Form

Please enable JavaScript in your browser to complete this form.

1New Patient Form

2Patient Medical Hisotry

3HIPAA Permissions

4Medical Release Form

Patient Full Name

First Name

Middle Name

Last Name

Maiden Name

Layout

Legal Gender

Date of Birth

Layout

Email Address

Zip Code

Address

Cell Phone

City

State

Preferred Form of Contact

Layout

Why do you seek to be seen?

Preferred Pharmacy address

Insurance name

ex. Aetna

Insurance ID#

What Date / Time would you prefer to be seen?

Date

Time

Principle person on insurance if not yourself

Emergency Contct:

Layout

First Name

Last Name

Primary Phone

Relationship to Patient

Patient Occupation Information:

Layout

Occupation

Position

Employer Name

Layout

Consent for Treatment and Notice of Deemed Consent to HIV Blood Testing

By selecting the box below, I acknowledge that I understand and/or agree to the following statement:

Check Below

I authorize City Mind NP providers (CMNP) to provide treatment to myself /or my dependent(s). I understand that the services that CMNP are voluntary and that I have a right to refuse treatment(s) before they are rendered. I understand that while receiving treatment, it is possible a healthcare worker may become directly exposed to my blood/body fluids or that of my dependent (s). In case exposure occurs, which according to the Centers of Disease Control Guidelines, transmit AIDS (Acquired Immune Deficiency Syndrome) a sample of my blood or my dependent will be collected and tested for the presence of infectious diseases like HIV, Hepatitis C, and Syphilis. I consent that the result be released to me and the exposed health worker. I understand the procedure will be explained to me and I will give the opportunity to ask questions about the procedure.

How did you hear about us?

Communication Agreement

By selecting the boxes below, I acknowledge that I understand and/or agree to the following statement(s):

Email:

This policy is for patients that allow City Mind NP to communicate to them via a password-protected email that the patient checks minimally three (3) times per week. CMNP will only communicate electronically with the email that you have provided as approved for communication. This email will not be provided to any third-party unless this third-party is for submission of payment or legally subpoenaed. CMNP cannot guarantee privacy or security of any message sent via email. There is the potential for interception of email communications from third-party entities.

Phone:

I understand the method of contacting the office, my provider, or any ancillary staff member must be done via 1 (888) 298-3220 or by responding to an email sent by CMNP. If a phone call attempt is not received by our office, please leave a fully detailed message spoken clearly including your DOB, full name, and concern. A member of staff at CMNP will return your call within seventy-two (72) hours. Missed calls without a voicemail will not be returned.

Social Media:

I understand that using social media, including, but not limited to TikTok, Facebook, Instagram, Twitter, LinkedIn, or other platforms are not admissible forms of communication. These forms of communication cannot guarantee privacy or prevention of interception and therefore will not be used. Any attempts to communicate using social media will not be acknowledged.

Telemedicine:

I authorize City Mind NP to perform telemedicine visits (“appointments”) using live video meetings. If the telemedicine platform has a technical failure the provider will immediately call the patient at the phone number provided to attempt to re-establish telemedicine connection. If failure continues after attempting to re-establish a telemedicine appointment, then the visit (“appointment”) will be resumed via telephone call or rescheduled. If the patient experiences any technical difficulties on their end, the patient will call CMNP at 1 (888) 298-3220 so staff may help with troubleshooting. Any sign-in beyond 15 minutes of the scheduled appointment time is considered a 'no-show' and is subject to the 'no-show' rescheduling fee of $25.

Appointment Policy

By selecting the box below, I acknowledge that I understand and/or agree to the following statement:

Appointment Policy

I understand that it is my responsibility to schedule appointments in a timely fashion and I am expected to keep all appointments scheduled with the provider. I am expected to arrive at least 20 minutes before my appointment time as a new patient or at least at the scheduled time for a follow-up appointment; I understand that failure to do so may result in my appointment being rescheduled. Furthermore, I understand that I will keep appointments that are scheduled at a future date and that cancellations must be done in more than forty-eight (24) hours ahead of a scheduled appointment. Failure to cancel an appointment greater than forty-eight (24) hours ahead of a scheduled appointment will result in a $25 cancellation penalty. Also, failure to keep scheduled appointments may result in not receiving prescriptions, testing, and/or other related care being delivered on time. I understand that if I have been subjected to a cancellation penalty that I must pay the balance of the penalty prior to be given an opportunity to schedule future appointments. I understand that if after multiple no shows or late arrivals, I may be discharged from the practice.

Patient Name

First

Middle

Last

Layout

Patient or Representative's Signature:

Today's Date:

Relationship to Patient:

If signing as patient representative

Layout

Name of Current Physician

Pharmacy Name

List all allergies (dietary, cosmetics, environmental, medication, etc):

Do you follow a particular dietary protocol? If so, list and breifly explain here.

List of surgical history, if any:

Phone Number

Pharmacy Phone

List all medications (and doses) you are now taking:

Do you follow a particular exercise regimen? If so, list and breifly explain here.

List of hospitalizations or injuries, if any:

Date of Last Visit

Pharmacy Fax

List all supplements (and doses) you are now taking:

List of any and all medical diagnoses or conditions, if any:

Family Hostory

Please list all medical conditions, if applicable, associated with the following biological relatives:

Layout

Mother

Sister

Grandmother

Father

Brother

Grandfather

Social History

Layout

Spouse's Name

Do you use alcohol-containing products?

Ages and gender of children

Do you use caffeine-containing products?

What is your highest level of education?

Do you use nicotine-containing products?

Billing/Financial Policy

By selecting the boxes below, I am acknowledging that I understand and/or agree to the following statements:

Policy 1:

I authorized CMNP to act on my behalf in filing appeals for denial of services by my insurance company. I understand that I am responsible to CMNP for the charges that are not covered for my insurance including, co-payment, deductibles and fees for services not covered by my insurance. Upon default on any payment due to CMNP, I agree to pay all cost of collections including collection agency fees up to 40%. Any balance remaining in my account after my insurance has paid for services will be payable by me. I understand that co-payments and deductibles are due prior to visits. Furthermore, I understand that failure to cancel or reschedule a new patient appointment in greater than forty-eight (24) hours prior to the scheduled time will incur a $25 cancellation penalty. I understand that I must remit the cancellation penalty if I want to reschedule this initial appointment. In addition, I understand that a fee of $25 (PAID IN CASH or MONEY ORDER) will be charged for any return check. I understand that a fee of $25 will be charged for any additional form such as DMV, FMLA that may be requested.

Layout

Patient or Representative's Signature:

Today's Date:

Relationship to Patient:

If signing as patient representative

Podcast Episodes

City Mind NP Psychiatry, P.C.

City Mind NP - New Patient Form

Emergency Contct:

Patient Occupation Information:

Consent for Treatment and Notice of Deemed Consent to HIV Blood Testing

Communication Agreement

Appointment Policy

Family Hostory

Social History

Billing/Financial Policy

HIPAA

HIPAA Authorization for Medical Record Release

Information to be disclosed

Authorization for Medical Record Release

Notice of Privacy Practice/Notice of Consumer Right

Acknowledgement/Certifications

Better Thoughts For Better Living

Quick Links

Resources

Let Us Help You