New Patient Intake Form – Adults | Dr. Cortman & Associates

Please only complete this form if you are a new patient to Dr. Cortman & Associates.

- Step 1 of 11

Today's Date: *

Patient's Legal Name: *

First

Last

Date of Birth: *

Age: *

Social Security Number: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone: *

Alternate Phone:

Email *

Please note: Email correspondence is not considered to be a confidential medium of communication.

Referred by:

Name of present physician:

Height:

Weight:

Current Medications:

Name of Medication #1

Dosage *

Frequency *

Route *

Name of Medication #2

Include name, dosage, frequency and route.

Dosage *

Include name, dosage, frequency and route.

Frequency *

Include name, dosage, frequency and route.

Route *

Include name, dosage, frequency and route.

Name of Medication #3

Dosage *

Frequency *

Route *

Please upload a separate page if more room is needed.

Click or drag a file to this area to upload.

Over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements:

Name of Supplement #1

Dosage *

Frequency *

Route *

Name of Supplement #2

Dosage *

Frequency *

Route *

Name of Supplement #3

Dosage *

Frequency *

Route *

Please upload a separate page if more room is needed.

Click or drag a file to this area to upload.

If you would like to upload a copy of your insurance card here, please do so. (If you do not upload those here, you will need to submit a copy to the office in order to be scheduled for your initial appointment.)

Click or drag a file to this area to upload.

Do you use tobacco in any form? *

If yes, please complete the following Tobacco Use Assessment Form. If no, please scroll down and move on to the next page.

Tobacco Use Assessment Form

Please only complete the form on this page if you answered "yes" to the above question.

1. Have you ever smoked cigarettes or used any other tobacco product?

2. Do you currently smoke cigarettes or use any other tobacco product?

If no, please include the date stopped:

If you answered "yes" to question #1 or #2 above, please answer the following:

Type of tobacco and brand name:

Length of use (in months or years):

Amount used per day on average:

Does anyone you live with or who is close to you smoke cigarettes or use other forms of tobacco?

Continue only if you answered "yes" to question #2 at the top of this form:

How soon after you wake up do you smoke your first cigarette or use other forms of tobacco?

Within 30 minutes
More than 30 minutes

How interested are you in stopping smoking or stopping use of other forms of tobacco?

Not at all
A little
Some
Very

If you decided to quit smoking or using other forms of tobacco completely during the next 2 weeks, how confident are you that you would succeed?

Not at all
A little
Some
Very

Have you ever intentionally quit smoking/using other forms of tobacco for 24 hours or longer?

In the past month?

In the past year?

Do you have Hypertension/High Blood Pressure? *

If yes, do you take meds?

When was your last blood pressure reading? *

Reading: *

Are you: *

Single
Married
Partnered
Separated
Divorced
Widowed

If partnered, is it OK to share appointment information with your spouse/partner? *

If parterned, is it OK to share billing/insurance information with your spouse/partner? *

If yes, spouse/partner name:

If your spouse is a policy holder on your insurance, please provide:

Spouse's name:

Date of birth:

Are you: *

Employed
Not Employed
Retired
Disabled
Student

If employed, are you:

Full time
Part time

Employer:

Occupation:

Length of time in this position:

Highest level of education: *

List any special areas of interest or hobbies (art, books, physcial fitness, etc.) *

Briefly describe your reason for seeking counseling: *

Please check any of the following that apply to you: *

Aggression
Delusions
Fears
Outbursts
Mood swings
Weight issues
Medical issues
Anxiety
Drug use
Gambling
Impulsivity
Laziness
Memory problems
Money troubles
Distraction
Emptiness
Grief
Infidelity
Stress
Self-esteem
Sexual issues
Confusion
Failure
Guilt
Loneliness
Panic
Suicidal thoughts
Obsessions
Fatigue
Headaches
Low mood
Withdrawal

If there is any additional information you would like to share, such as past traumatic experiences, abuse, or anything you feel is relevant that he/she should be aware of in order to provide the best treatment possible, please do so below.

Confidentiality Form, Financial Responsibility and Insurance/Medicare Agreement

In accordance with the health Insurance Portability & Accountability Act of 1996 ("HIPAA") which is a Federal Law, it is the policy of Dr. Cortman and/or members of his staff to not release confidential and/or unauthorized information. Dr. Cortman and/or members of his staff may leave medical information pertaining to my appointments on the telephone number(s) and/or by using the address provided on the intake information form. You will assume responsibility to notify Dr. Cortman and staff whenever this information changes. If you authorize healthcare information to be released to ANYONE ELSE, please complete the following:

I release my medical information to:

Name/Relationship

I release my medical information to:

Name/Relationship

In exhange for Dr. Cortman's and/or a member of his staff's agreement to prov ide professional serices, YOU AGREE TO PAY THE FEES for such services. Payment is due at the time services are provided unless other arrangements have been agreed to in writing prior to the services being provided. Availability of insurance coverage or the agreement of another person to be responsible for the payment of fees for services do not relieve you (or you on behalf of your minor child) of responsibility for the payment due. IF USING INSURANCE AND/OR MEDICARE, you authorize the release of any medical or other information necessary to process the claims for services provided and payment of medical benefits to Dr. Cortman and/or a member of his staff for the services provided. You AGREE TO PAY INTEREST at the rate of eighteen percent (18%) per year on any balance due which you fail to pay within sixty (60) days. You further agree that you will pay the costs of collection, including attorney's fees, if Dr. Cortman and/or a member of his staff must take any action to collect an overdue payment. THIS AGREEMENT SHALL REMAIN IN EFFECT until you (or your minor child) professional services rendered have been paid in full.

By typing my name below, I agree to all of the above. *

Print name

Date *

24 Hour Cancellation Policy

IF YOU NO-SHOW OR CANCEL YOUR APPOINTMENT WITH LESS THAN 24 HOURS NOTICE, YOU WILL BE CHARGED $100.00 FOR THE MISSED APPOINTMENT.

You will never be charged for a cancellation if it is made at least 24 hours in advance of your scheduled appointment time. Reason for this policy: Notifying us of your intention to cancel or reschedule 24 hours in advance gives us an opportunity to schedule someone else for that time slot. This is important because others may be on a wait list or may also be looking for an opportunity to reschedule for a different time. As much advance notice as possible is always appreciated.

This cancellation policy is standard in the medical and mental health fields and will be strictly enforced. On occasion, there will be understandable reasons for msising appointments, but exceptions to this policy will be rare.

Teleheath Sessions

Due to the Coronavirus outbreak, we are currently only offering telehealth sessions. Most insurance providers provide the same coverage for telehealth appointments as they would for comparable in-office visits. However, some plans may still refuse to cover telehealth visits, as this is is up to the insurance provider. We are in-network for Medicare and out-of-network for all other insurances. Although we accept most major insurance plans, we encourage telehealth patients to check with their insurance companies about telehealth coverage before their appointments. We DO NOT accept Medicaid, even as a secondary insurance.

Third party breaches are possible and these breaches are the largest associated risk with using telehealth services. We continue to follow ethical standards for privacy and confidentiality when using telehealth services. There should be no additional cost as a user of telehealth unless you have limited internet usage in your home. Please ensure the Wi-Fi connection you are using for telehealth services is password protected and secure. Telehealth services vary state by state. If you currently live outside of the state of Florida, your session may not be covered by insurance. You must let our staff know if you are not in Florida prior to scheduling an appointment. There are some potential benefits and risks of telehealth (e.g. miscommunication, missed non-verbal cues, household noise or interruptions, increased flexibility, convenience) that differ from in-person sessions. It is important during telehealth sessions that your clinician has a phone number where you can be reached if services are disconnected.

Please note: A session is between 45-55 minutes in length. Please sign below to indicate you have read, understand, and agree. *

First

Last

Date *

Notice of Privacy Practices Acknowledgment

Under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA "), you have certain rights to privacy regarding your protected health information. Your information can and maybe used to:

- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly.

- Chain payment from third-party payers.

- Conduct normal healthcare operations, such as quality assessments and physician certifications.

Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information is available upon request this organization has the right to contact its notice of privacy practices from time to time but you may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.

If you have been referred by your physician, please read and complete one of the following options:

By checking this box I consent to send a one time letter to my physician confirming that I have met with a therapist. No further correspondence will be sent without your consent.
By checking this box I do not consent to send a confirmation letter to my physician.

Name *

First

Last

Date *

GAD-7

Over the last two weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious or on edge *

Not being able to stop or control worrying *

Worrying too much about different things *

Trouble relaxing *

Being so restless that it is hard to sit still *

Becoming easily annoyed or irritable *

Feeling afraid as if something awful might happen *

Patient Health Questionnaire - 9 (PHQ-9)

Over the last two weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things *

Feeling down, depressed or hopeless *

Trouble falling or staying asleep, or sleeping too much *

Feeling tired of having little energy *

Poor appetite or overeating *

Feeling bad about yourself - or that you are a failure or have let yourself or your family down *

Trouble concentrating on things, such as reading the newspaper or watching television *

Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual *

Thoughts that you would be better off dead or of hurting yourself in some way *

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult

Elder Abuse Suspicion Index (EASI)

Must be completed by all patients 65 years old or older

Name

First

Last

Date

Relied on people for any of the following: bathing, dressing, shopping, banking or meals?

Has anyone prevented you from getting food, clothes, medication, glasses, hearing aides or medical care, or from being with people you wanted to be with?

Have you been upset because someone talked to you in a way that made you feel shamed or threatened?

Has anyone tried to force you to sign papers or to use your money against your will?

Has anyone made you afraid, touched you in ways that you did not want to, or hurt you physically?

Credit Card Authorization Form

Patient name: *

First

Last

Name on card: *

First

Last

Credit Card #: *

Credit card type: *

Visa
MasterCard
AMEX
Discover

Expiration: *

Security Code: *

Billing Address for card: *

Address Line 1

Address Line 2

City

State

Zip Code

By signing below, I hear by authorize Dr. Cortman & Associates to charge my credit card for services rendered.

Signature: *

First

Last

Date: *