Donald Slutzky, M.D.
2429 BATH STREET
SANTA BARBARA, CALIFORNIA 93105-4324
TEL: 805-243-8386
FAX: 805-687-2442
Certified in Psychiatry by the American
Board of Psychiatry & Neurology
Patient Intake Questionnaire
Please read the following questionnaire and answer as many of the questions that you can. Answering everything is not mandatory but In order to determine how I might be able to help please write me a couple of paragraphs about yourself.After you send your response to me give me a day or so and then call me at 805-243-8386 about an appointment and please tell me the best days and times for you.
If you are contacting me about your child or dependant, please respond to the specific questions about background from your child’s perspective. Also let me know what you see with regard to the child’s manner, personality, and behavior. If your child is of an age at which he/she would like to respond to me by e-mail directly please have him/her do so.
Please have previous psychiatric, psychological, medical, or other relevant records sent to me preferably by email at ,or by fax (805)687-2442.
Please contact your insurance company to see if you need prior authorization to see me and request it if you do. Make sure to bring your insurance card with you to the first meeting for verification.
Please call me 1-2 days after sending back the information. One of my associates or I will quickly get back to you.Let me know appointment times that are best for you: Mondays, Tuesdays or Wednesdays.
There is a charge for missed appointments and cancellations within 24 hours of an appointment, including the first scheduled appointment.
My email: My website:
Office Location: 2429 Bath, Santa Barbara. It is 1/2 block north of Cottage Hospital on the same (west) side of Bath street
Billing and questions about insurance: Mr. Pabst, Telephone: 805-308-3707, FAX: 206-202-4772, e-mail:
Directions:
Coming from the North: Southbound 101 exit at Mission turn left, go 1 block to Bath and turn left.
Coming from the South: Northbound 101 exit at Mission turn right, go 1 block to Bath and turn left.
Go North on Bath Street for 4 blocks, passing Cottage Hospital on the left. My office is on the left (west) of Bath Street. You can park on the front of the property. Please come at least 15 minutes before your scheduled appointment time.
I’d like to know
Something about why you are coming to see me, where you were born, your birthdate, where you went to school, if you liked school, did well, what jobs you’ve had and for how long and if you liked them. I would like to know about your mom, dad, & siblings, their ages, health, relationships with you, where they live, & how often you are in touch, about your marital history, spouse's job, your kids' ages, their father(s)/mother(s) and your medical history, psychiatric history, legal history, history of alcohol or drug use or abuse, history of counseling, how the kids are doing, family history of any medical or psychiatric illnesses or injuries. Family History of taking psychiatric medicines and which ones that were helpful and which ones weren’t I’d like to know if you’ve seen counselors, psychiatrists, have any medical conditions, take or have taken any medicines, including psychiatric medicines. Has your weight been stable? Do you sleep well? Do you get some exercise? What do you do in your free time? Do you have any allergies? What are your goals?
Background Information
Patient Name:
PATIENT INFORMATION/INSURANCE
Patient Name:
Date of Birth:
Social Security #
Sex:
Marital Status:
Address:
Phone, Home:
Phone, Work:
Phone, Cell:
Email Address:
Will you accept receipt of statements through email?
Employer:
Attorney Name and Phone (if workers comp)
Responsible Party/Parent Information (If different from above)
Name:
Date of Birth:
Social Security #
Sex:
Marital Status:
Address:
Phone, Home:
Phone, Work:
Phone, Cell:
Email Address:
Will you accept receipt of statements through email?
Employer:
Primary Insurance Information
(You Must Contact Your Insurance To Arrange Authorization Prior To First Visit!)
Insurance Name:
Name of Mental Health Processors (if different from above):
Phone:
Billing Address for Mental Health Claims:
Insured’s Name:
Insured’s Date of Birth:
Group Number:
ID Number:
(For Tricare this is your SS#. All others MUST include any letter prefixes)
Workers Comp Claim Number:
Date of Injury:
Secondary Insurance Information
(You Must Contact Your Insurance To Arrange Authorization Prior To First Visit!)
Insurance Name:
Name of Mental Health Processors (if different from above):
Phone:
Billing Address for Mental Health Claims:
Insured’s Name:
Insured’s Date of Birth:
Group Number:
ID Number:
(For Tricare this is your SS#. All others MUST include any letter prefixes)
I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges, including Deductibles and Copayments, whether or not they are covered by insurance. Note that No Shows/Late Cancellations will be billed to you at a minimum rate of $75; phone consults will be billed to you at rate of $15-$100 (dependant on length of call) as they are not covered by insurance; Rx refill requests (outside and office visit) will be billed to you at a rate of $10-$25 dependent on time spent consulting with pharmacist. I Authorize ALL Insurance, Settlement and Other payments to be made directly to Donald Slutzky, MD.
Electronically Signed (type name and date here):
DONALD SLUTZKY, M.D.
2429 BATH STREET
SANTA BARBARA, CALIFORNIA 93105-4324
805-687-5491
PLEASE READ THIS NOTICE CAREFULLY BEFORE SIGNING
DEAR PATIENT:
WELCOME TO THE MEDICAL PRACTICE OF DONALD SLUTZKY, M.D. I WANT TO PROVIDE YOU WITH THE BEST MEDICAL TREATMENT POSSIBLE. IN ORDER TO DO THAT, THERE ARE SOME POINTS THAT I WOULD LIKE TO BRING TO YOUR ATTENTION:
WHEN MAKING APPOINTMENTS, PLEASE NOTE THAT I REQUIRE A MINIMUM CANCELLATION NOTICE OF 24 HOURS. ANY NOTICE OF CANCELLATION LESS THAN 24 HOURS OR ANY MISSED APPOINTMENT WITHOUT PROPER NOTIFICATION IS SUBJECT TO A MINIMUM FEE OF $75 AND A MAXIMUM FEE EQUAL TO THAT OF THE MISSED APPOINTMENT. YOUR INSURANCE COMPANY WILL USUALLY NOT PAY FOR MISSED APPOINTMENTS
CASE MANAGEMENT (PHONE CONSULTATIONS) ARE NOT USUALLY COVERED BY INSURANCE. FEES OF $15 TO $75 WILL BE BILLED TO THE PATIENT FOR THESE SERVICES. REQUESTS BY PATIENTS AND PHARMACIES TO REFILL PRESCRIPTIONS OVER THE PHONE WILL BE BILLED TO THE PATIENT AT A FEE OF $10 TO $25.
ALL FEES AND CO-PAYS ARE DUE AND PAYABLE UPON COMPLETION OF YOUR VISIT, UNLESS OTHER FINANCIAL ARRANGEMENTS HAVE BEEN MADE. OUTSTANDING BALANCES OVER 60 DAYS OLD WILL BE BILLED A FINANCE CHARGE.
IF YOU HAVE INSURANCE, I WILL HAVE YOUR INSURANCE BILLED AS A COURTESY. BUT THAT DOES NOT GUARANTEE PAYMENT. PLEASE PROVIDE US WITH PROPER INSURANCE IDENTIFICATION AND/OR DOCUMENTS. YOU ARE RESPONSIBLE FOR INITIATING ANY AUTHORIZATIONS NECESSARY WITH YOUR INSURANCE COMPANY. IN THE EVENT THAT YOUR INSURANCE CLAIM IS DENIED, YOU, THE UNDERSIGNED WILL BE FINANCIALLY RESPOSIBLE FOR FEES INCURRED THROUGH MEDICAL SERVICES RENDERED.
PLEASE NOTIFY ME OF ANY CHANGES REGARDING YOUR ADDRESS, PHONE NUMBER, BENEFITS AND/OR INSURANCE COMPANY.
PATIENTS RIGHTS INCLUDE: PERSONAL PRIVACY AND CONFIDENTIALITY OF INFORMATION (DETAILS AVAILABLE ON REQUEST); ACCESS TO CARE, REGARDLESS OF RACE, RELIGION, GENDER, SEXUAL ORIENTATION, ETHNICITY, AGE OR DISABILITY; ABILITY TO DISCUSS WITH THEIR PROVIDERS THE MEDICALLY NECESSARY TREATMENT OPTIONS FOR THEIR CONDITION; ACCESS TO INDIVIDUALIZED TREATMENT.
PATIENTS RESPONSIBILITIES INCLUDE: GIVING THEIR PROVIDER INFORMATION NEEDED IN ORDER TO RECEIVE CARE; TO FOLLOW THEIR AGREED UPON TREATMENT PLAN AND INSTRUCTIONS OF CARE; TO PARTICIPATE IN UNDERSTANDING THEIR BEHAVIORAL HEALTH PROBLEMS AND DEVELOPING WITH THEIR PROVIDER MUTUALLY AGREED UPON TREATMENT GOALS.
I, THE UNDERSIGNED, HAVE READ THIS INFORMATION AND UNDERSTAND THE GUIDELINES SET FORTH FOR CANCELLED AND MISSED APPOINTMENTS, BILLING OF PRIVATE INSURANCE, PAYMENT ARRANGEMENTS AND PHONE CONSULTATIONS.
NAME:
ELECTRONICALLY SIGNED:
DATE: