Florida Center for Brain and Mind

Florida Center for brain and Mind

900 SE Ocean Blvd.

Suite D-130

Stuart, FL 33994

Dear Patient,

We would like to welcome you to our practice. We are providing you with this informational letter to help with your registration process. Please read this information carefully. Should any questions arise, please do not hesitate to discuss them at your appointment.

1. For your convenience, you may download a map to our office from our website at . Our address is 900 SE Ocean Blvd.,Suite D-130.

2. Please arrive to the first appointment with your paperwork completely filled out, along with your insurance card(s) and any other paperwork requested by our office. This will allow us to serve you in the most time efficient manner possible. If the information cannot be completed prior to your appointment, please arrive 30-45 minutes early in order to complete the forms. While there may be some information that you cannot answer, please do your best to provide as much information as you can. You will not be seen unless all forms are filled out prior to your visit.

3. It is our office policy that you provide us with full payment/co-payment at the time of each visit.

APPOINTMENTS

Initial intake interviewsand follow-up psychotherapy sessions are approximately 50-55 minutes long. Other types of evaluations and neuropsychological testing may involve greater amounts of time.

CANCELLATIONS

When you schedule an appointment, the doctor’s time is reserved just for you. Unlike other physicians, we do not double/triple-book appointments. For this reason, a minimum of 24 hours’ notice is required,should you cancel or re-schedule an appointment.A charge of$50.00 will be placed on your accountfor missed appointments and appointments which are canceled with less than 24 hours’ notice. In the case of evaluations where multiple hours of testing have beenscheduled, you will be charged $50.00 for each scheduled hour.

CONFIDENTIALITY AND RELEASE OF INFORMATION

Information disclosed within sessions and the written records pertaining to those sessions are confidential and will not be released to anyone without written consent of the patient, or the guardian, in the case of dependent adults.

However, we are required by Florida law to make areportin certain circumstances:

1. When patients pose an imminent threat of danger to themselves or others.

2. In instances of suspected abuse or neglect of a child (physical, sexual and/or emotional

abuse).

3. In instances of suspected abuse or neglect of a dependent adult.

Disclosure may also be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony.

In family therapy, or when different family members are seen individually, confidentiality and privilege may not apply among family members. Our doctor will use clinical judgment when revealing such information.

Disclosure of confidential information may be required by your health insurance or EAP in order to process your claims. Only the minimum necessary information will be communicated to the carrier.

PSYCHOLOGICAL AND NEUROPSYCHOLOGICAL SERVICES

Psychotherapy requires a very active effort on your part. In order to be most successful, you may need to work onthings at home that you and your doctor talk about during your sessions. This also means that you need to keep regularly scheduled, weekly appointments, so that continuity, consistency and stability can become the foundation of successful treatment.

For those interested in psychotherapy: Psychotherapy has both benefits and minimal risks. Benefits include reduction of feelings of distress, better relationships, improvement in thinking skills and overall better health and well-being. Occasionally, during the process, patients may experience some uncomfortable feelings, however, overall benefits generally outweigh the risks, and psychotherapy is likely to have excellent benefits for your future to come.

For those interested in neuropsychological assessment: Please be aware that the evaluation process may include tests that are challenging and exceed the limits of your cognitive abilities. We want to obtain your best performance because this is the only way to identify your true strengths and weaknesses. Prior to your visit, please let us know of any medications you plan to take on the day of your assessment. We may ask you to stop a specific medication 24 hours prior to your evaluation, with your physician’s approval. Although not expected, should you have any discomfort at the time of testing, please let us know immediately, so that these problems can be immediately addressed.

We continually strive to provide you with excellent care. Please do not hesitate to contact us with any questions.

Thank you for choosing Florida Center for Brain and Mind as your provider for mind and brain care.

CONSENT TO RECEIVE PSYCHOLOGICAL SERVICES

AND ASSIGNMENT OF BENEFIT

I FULLY UNDERSTAND THAT I AM GIVING MY WRITTEN CONSENT TO RECEIVE PSYCHOLOGICAL SERVICES.

I AGREE THAT THESE SERVICES ARE MUTUALLY UNDERSTOOD TO BE APPROPRIATE, AND THAT I MAY WITHDRAW MY CONSENT AT ANY TIME.

I AUTHORIZE DR. JUDITH HORVATH, PH.D., ABPP TO OBTAIN AND RELEASE INFORMATION REGARDING MY TREATMENT TO THE REFERRING PROVIDER WHO PRESENTS A VALID NEED FOR SUCH INFORMATION, AS DETERMINED BY THE PROVIDER.

I AUTHORIZE RELEASE OF MEDICAL INFORMATION NECESSARY TO PROCESS CLAIMS FOR SERVICES RENDERED ON MY BEHALF. FOR THESE SERVICES I AUTHORIZE PAYMENT DIRECTLY TO DR. JUDITH HORVATH, PH.D., ABPP BY MEDICARE, HEALTH INSURANCE, AND/OR THIRD PARTY BENEFITS.

WHEN PAYMENT FOR SERVICES RENDERED IS VIA PRIVATE PAY, I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO PAY AT THE TIME THE SERVICES ARE RENDERED.

I UNDERSTAND THAT MY SIGNATURE BELOW WILL ACT AS A SIGNATURE ON FILE.

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Signature of Patient/Legal GuardianDate

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Print patient’s name

______

Signatureof WitnessDate

CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

PATIENT'S NAME: ______

DATE OF BIRTH: ______

SOCIAL SECURITY NUMBER: ______

I ______AUTHORIZE THE FOLLOWING:

DR. JUDITH HORVATH, PH.D., ABPP MAY RELEASE INFORMATION REGARDING MY PSYCHOLOGICAL EVALUATION AND TREATMENT TO

(INSURANCE CARRIERS GENERALLY REQUIRE THAT WE COMMUNICATE WITH YOUR PRIMARY CARE PHYSICIAN AND/OR REFERRING PHYSICIAN):

NAME OF PHYSICIAN: ______

ADDRESS: ______

______

PHONE: ______

OR

THE FOLLOWING AGENCY/PROFESSIONAL______

***********************************************

______MAY RELEASE INFORMATION REGARDING MY MEDICAL AND/OR PSYCHIATRIC EVALUATION AND TREATMENT TO:

DR. JUDITH HORVATH, PH.D., ABPP.

This release is limited to that information which is necessary for effective case management and treatment. I understand that material may include information regarding drug and/or alcohol use if it was reported in my record. Additionally, information regarding my health status and HIV status may be released if it is contained in the record. I may revoke this consent at any time.

______

Signature of Patient/Legal GuardianDate

______

Print patient’s name

______

Signatureof WitnessDate

FINANCIAL FORM

Patient's Name:

______

Subscriber’s Name: ______

Date of Birth of Subscriber: ______Marital Status: ______

Address of Subscriber: ______

Primary Insurance ______

Name of company(if BC/BS - which state) ______

Policy number (including suffix)

______

Groupnumber

Secondary Insurance______

Name of company (if BC/BS - which state)______

Policy number (including suffix)Group number

______Provider of services accepts assignment. The patient /legal guardian will be responsible for any amount not covered by insurance. (please initial)

______Provider of services cannot accept assignment. The patient/legal guardian will be responsible for payment on services rendered. (please initial)

______Payment/Copayment Is Due at the time of service. (please initial)

I understand my responsibility: yes  no

I am aware that I need to make co-payment/payment: yes  no

I am aware of the cancellation policy(if notice given less than 24 hours): yes  no

______

Signature of Patient/Legal GuardianDate

______

Print patient’s name

______

Signatureof WitnessDate

OFFICE POLICY FOR PAYMENT OF SERVICES

Payment is due at the time services are rendered. We accept cash, checks, MasterCard, Visa, American Express, and Discover. As a courtesy, we will estimate your insurance portion and process your claims for you. You will be required to pay your estimated patient portion on the day services are rendered (deductible, copay and/or coinsurance). Not all services are a covered benefit in all contracts. You are responsible for any balance remaining after insurance pays their portion.

We require a credit card number to be kept on file, authorizing any overdue balance to be charged to the card. For patients without insurance, the credit card would be charged for any outstanding balances. For patients with insurance, the credit card would only be charged in case the insurance company fails to pay after 30 days of filing, denies payment, or to cover the balance remaining after the insurance company has paid their portion. We will notify you by phone or email prior to charging your account. Returned checks and balances older than 30 days may be subject to additional collection fees and interest charges of 1.5% per month.

I understand that I am responsible for the charges not covered by insurance which are allowable by contract and by law. I hereby guarantee prompt payment of all charges incurred for services rendered not covered by insurance carriers or others. Payment will be made of any overdue balance within 30 days of billing. If payment is not received within 30 days, finance charges may begin to accrue at the maximum rate allowable by law. I agree that my credit card can be billed for any outstanding balance. If payment is not received within 30 days of the date such balance is due, the bill may be turned over to an attorney or a collection agency, at which time the undersigned shall be liable for attorney’s fees and/or collection agency’s fees and expenses.

PATIENT NAME: ______

RESPONSIBLE PARTY:______

CARD HOLDER NAME: ______

CARDHOLDER ADDRESS: ______

CITY: ______STATE: ______ZIP: ______

ACCOUNT NUMBER: ______EXP DATE: ______

CVS CODE: ______

AUTHORIZATION SIGNATURE: ______

DATE: ______

CONSENT TO USE AND/OR DISCLOSE

PROTECTED HEALTH INFORMATION FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

As a condition of providing treatment to you, DR. JUDITH HORVATH, PH.D., ABPP may request your consent to use and disclose protected health information about you to carry out treatment, payment, and health care operations.

You may revoke this consent at any time by notifyingDR. JUDITH HORVATH, PH.D., ABPP in writing, except to the extent that the provider has taken action and reliance on your consent.

Please refer to the Notice of Privacy Practices for Protected Health Information (“Privacy Notice”) for a more complete description of the uses and disclosures that DR. JUDITH HORVATH, PH.D., ABPP may use of your protected health information. You have the right to review the Privacy Notice prior to signing this consent.

DR. JUDITH HORVATH, PH.D., ABPP has reserved the right to change its privacy practices described in this Privacy Notice. In accordance with law, the terms of the Privacy Notice may change. At any time, you may obtain a copy of the current Privacy Notice and any revised notice.

You have the right to request that DR. JUDITH HORVATH, PH.D., ABPP restrict the manner in which your protected health information is used or disclosed to carry out treatment, payment, or health care operations. The provider is not required, however, to agree to such requested restrictions. If, however, the provider agrees to the requested restriction, the provider will honor the request and it will be binding.

I hereby consent to the use and disclosure by my provider, its workforce, and its business associates of my protected health information for purposes of treatment, payment, and health care operations.

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Signature of Patient/Legal GuardianDate

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Print patient’s name

______

Signatureof WitnessDate

APPOINTMENT REMINDERS AND

ONLINE APPOINTMENT SCHEDULING

You can choose to receive an appointment reminder to your email address, your cell phone (via a text message), or your home phone (via a computer generated voice message) before your scheduled appointments.

Your name: ______

Your email address: ______

Your cell phone number: ______

Where would you like to receive appointment reminders? (check one)

_____ Via a text message on my cell phone (normal text message rates will apply)

_____ Via an email message to the address listed above

_____ Via an automated telephone message to my home phone

_____ None of the above. I’ll remember my appointments on my own.

(Missed appointment fees will still apply)

Appointment information is considered to be “Protected Health Information” under HIPAA. By my signature, I am waiving my right to keep this information completely private, and requesting that it be handled as I have noted above.

______

Signature of Patient/Legal GuardianDate

______

Print patient’s name

______

Signatureof WitnessDate

PSYCHOLOGICAL/NEUROPSYCHOLOGICAL HISTORY

Date: ______Name of person filling out form: ______

Relationship to patient: ______

Patient’s Name: ______Sex: ______Age: ______Date of Birth: ______Marital Status: ______

HomeAddress: ______

Home Phone: ______Cell Phone: ______

Referred By: ______

Reason(s) for visit: ______

History of Present Condition:

Please describe onset of present condition, including dates, names of hospitals and physicians, types of treatment, etc.:

______

______

______

______

______

______

______

Symptom Survey

Place a check (X) beside each symptom that currently applies. Also underline the symptom, if it existed prior tocurrent condition.

1) PHYSICAL

__ Headaches

__ Dizziness

__ Nausea

__ Vomiting

__ Urinary incontinence

__ Loss of bowel control

__ Excessive tiredness

__Pain (indicate location): ______

__ Blackout spells (fainting)

__ Other physical problems: ______

2) SENSORY

Check the side it occurs on:

Right side Left side Both sides

__ Loss of feeling or numbness______

__ Tingling or strange skin sensations ______

__ Difficulty telling hot from cold ______

__ Problems seeing on one side ______

__ Blank spots in vision ______

__ Brief periods of blindness ______

__ Seeing "stars" or flashes of light ______

__ Double vision______

__ Difficulty looking quickly from one object to another object

______

__ Difficulty hearing ______

__ Ringing in ears ______

__ Hearing strange sounds______

__ Difficulty tasting food______

__Difficulty smelling______

__ Smelling strange odors______

__ Other sensory problems: ______

3) MOTOR AND COORDINATION Check the side this occurs on:

Right side Left side Both sides

__ Fine motor control problems (pencil) ______

__ Weakness on one side of body ______

__ Difficulty holding on to things ______

__ Tremor or shakiness ______

__ Muscle tics or strange movements ______

__ Writing is very small______

__ Writing is very large______

__ Walking more slowly than others______

__ Balance problems______

__ Difficulty starting to move______

__Jerky muscles______

__ Muscles tire quickly______

__ Often bumping into things______

__ Other motor or coordination problems: ______

4) NONVERBAL SKILLS

__ Difficulty telling right from left

__ Difficulty doing things that you should automatically be able to do

__ Problems drawing or copying

__ Problems finding way around places that you have been before

__ Difficulty recognizing objects or people

__ Difficulty with puzzles

__ Unaware of things on one side of your body: __ Right side __ Left side

__ Getting lost easily

__Inability to recognize facial or body expressions of disapproval or emotions

__ Slow reaction time

__Other nonverbal problems:______

5) SPEECH, LANGUAGE AND ACADEMIC SKILLS

__Inability to speak

__ Slurred speech

__ Odd or unusual speech sounds

__ Difficulty finding the right words to say

__ Difficulty expressing thoughts in an organized way

__ Difficulty staying with one idea during a conversation

__ Difficulty verbally describing the steps involved in doing something

__ Difficulty understanding what others are saying

__ Difficulty reading phonetically

__ Difficulty with reading comprehension

__ Difficulty writing letters or words (not due to motor problems)

__ Difficulty spelling

__ Difficulty with math

__ Other speech, language, or academic skills problems:______

6) CONCENTRATION AND AWARENESS

__ Highly distractible

__Losing train of thought

__ Problems concentrating

__Easily confused or disorientated

__ Mind appears to go blank at times

__Difficulty staying very alert or aware of things

__ Other concentration or awareness problems:______

7) PROBLEM SOLVING

__ Difficulty with reasoning or figuring out how to do new things

__ Difficulty with planning and organization

__ Difficulty figuring out problems

__ Difficulty thinking as quickly as needed

__ Difficulty doing things in the right order (sequencing problems)

__ Difficulty changing a plan or activity when necessary

__ Difficulty completing an activity in a reasonable amount of time

__ Difficulty doing more than one thing at a time

__ Difficulty switching from one activity to another activity

__ Other problem solving difficulties: ______

8) MEMORY

__ Forgetting where you leave things (e.g., books, etc.)

__ Forgetting names

__ Forgetting what you should be doing

__ Forgetting where you are or where you are going

__ Forgetting events that happened quite recently (e.g., your last meal)

__ Forgetting events that happened long ago (months or years)

__ Needing someone to give you a hint so you can remember

__ Relying more and more on notes or reminders to remember things

__ Forgetting the order of things (e.g., when putting something together, etc.)

__ Other memory problems: ______

9) BEHAVIOR AND EMOTIONAL FUNCTIONING

__ Suicidal thoughts

__ Homicidal thoughts

__ Depression/sadness

__ Anxiety/nervousness

__ Recurrent/intrusive thoughts

__ Nightmares

__ Loss of appetite

__ Recurrent/intrusive disturbing recollections or dreams

__Weight loss

__ Overwhelming need to perform certain behaviors/rituals

__ Overeating

__ Excessive fears or phobias

__ Weight gain

__ Significant concerns with physical problems

__ Difficulty sleeping

__ Poor frustration tolerance

__ Apathy

__ Explosive anger

__ Fatigue

__ Rapid mood changes

__ Loss of interest in almost all activities

__ Euphoria (feel on top of the world)

__ Feeling worthless

__ Racing thoughts

__ Feelings of hopelessness

__Decreased need for sleep

__ Poor self esteem

__ Aggressive

__ Sexual problems

__Visual or auditory hallucinations

__ Anorexia or Bulimia

__ Stomach aches

__ Unmotivated

__Bizarre behavior

__ Dependent

__ Shy and withdrawn

__ Quiet

__ Self-mutilating behavior

__ Resisting change

__ Self-stimulating behavior

__Wetting bed or clothes

__ Exhibiting sexually inappropriate behavior

__ Bowel movements in underwear

__ Risk-taking behavior

__ Emotional

__Cruelty to other people

__ Immaturity

__ Swearing a lot

__ Fidgety

__ Stealing things without people knowing on several occasions