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MEDICAL INTAKE FORM

INTAKE FORM

  • PERSONAL INFORMATION

  • PATIENT(S)

  • Date Format: MM slash DD slash YYYY
  • RESPONSIBLE PARTY

  • Emergency Contact

  • FINANCIAL

  • Date Format: MM slash DD slash YYYY
  • PRACTICE POLICIES

  • You will be evaluated by trained and licensed provider. We wish to take this opportunity to welcome you and also to state some basic principles we believe essential in establishing a good relationship between us. Please read through this information, asking questions as needed.

    1. INITIAL INTERVIEW: Your first history and physical is considered an evaluation interview and exam. At the time of this appointment, the following decisions will be made with you: a) If ketamine is an appropriate treatment option b) Frequency of ketamine infusion sessions c) Goals of therapy (what you hope to gain from this process.)
    2. APPOINTMENTS: Each appointment varies in length depending on your chief complaint. Typically, 40 min infusion appointments take just under 2 hours, 4 hour infusions are typically around 5 hours in length. At the end of each appointment you can make arrangement for your next appointment or you may also book all your prescribed appointments at once.
    3. CANCELLATIONS: If you find that you need to cancel an appointment, please give as much notice as possible so that we can schedule people that are on our waiting list. You will be personally charged for your appointment if not canceled at least 24 hours in advance other than for emergency reasons.
    4. PAYMENTS: We would greatly appreciate payment in full for each office prior to the start of your appointment. If you do not have a charge card. We will accept cash and check. Please make checks out to Illuminate Ketamine Center PLLC.
    5. INSURANCE: Insurance is an agreement between you and your insurance company as to how treatment will be paid for. We will assist you in any way possible by providing receipts and documentation. We currently do not directly participate with insurance plans. However, we will assist you in by giving you receipts to submit, and follow up contacts. Some insurance companies will pay for a portion of outpatient ketamine infusion services. You should check with your insurance company representative to find out specific requirements and limitations of this coverage. We will be happy to assist you in the preparation of insurance forms if you feel there is a chance your insurance company will pay for these services. The hourly rate will apply. Payments for services received through Illuminate Ketamine Center are ultimately your responsibility. If your insurance company requires that outpatient ketamine infusion services be preauthorized, it is your responsibility to initiate the reauthorization process, i.e. contacting your primary care physician, insurance company, or a third party “gate keeper”. Failure to obtain required preauthorization for outpatient mental health services will result in you being held 100% responsible for all charges.
    6. CONFIDENTIALITY: All information regarding the specific nature of your treatment is maintained at Illuminate Ketamine Center and is considered confidential within the office unless specified by you in writing. However, each provider at this office reserves the right to use specialty consultation with other medical providers at the office as deemed necessary. We follow HIPAA and maintain confidentiality.
  • Signature

  • Date Format: MM slash DD slash YYYY

HIPPA COMPLIANCE FORM

DEPRESSION FORM

BECK DEPRESSION INVENTORY

  • Date Format: MM slash DD slash YYYY
  • Questionaire

    This depression inventory can be self-scored. The scoring scale is at the end of the questionnaire.
  • The total score is calculated by finding the sum of the 21 items. Score of 0 – 10 = These ups and downs are considered normal. Score of 11 – 16 = Mild mood disturbance. Score of 17 – 20 = Borderline clinical depression Score of 21 – 30 = Moderate Depression Score of 31 – 40 = Severe Depression Score over 40 = Extreme Depression

PTSD FORM

PTSD Checklist Civilian Version (PCL-C)

  • Date Format: MM slash DD slash YYYY
  • The PCL is a standardized self-report rating scale for PTSD comprising 17 items that correspond to the key symptoms of PTSD. Two versions of the PCL exist: 1) PCL-M is specific to PTSD caused by military experiences and 2) PCL-C is applied generally to any traumatic event.

    The PCL can be easily modified to fit specific time frames or events. For example, instead of asking about “the past month,” questions may ask about “the past week” or be modified to focus on events specific to a deployment.

    How is the PCL completed? • The PCL is self-administered • Respondents indicate how much they have been bothered by a symptom over the past month using a 5-point (1-5) scale, circling their responses. Responses range from 1. Not at all - 5. Extremely

    How is the PCL scored? 1) Add up all items for a total severity score or 2) Treat response categories 3-5 (Moderately or above) as symptomatic and responses 1-2 (below Moderately) as non-symptomatic, then use the following DSM criteria for diagnosis: • Symptomatic response to at least 1 “B” item (Questions 1-5) • Symptomatic response to at least 3 “C” items (Questions 6-12), and • Symptomatic response to at least 2 “D” items (Questions 13-17)

    Are results valid and reliable? Two studies of both Vietnam and Persian Gulf theater veterans show that the PCL is both valid and realiable (Additional references are available from the DHCC)

    Are results valid and reliable? • All military health system beneficiaries with health concerns they believe are deployment-related are encouraged to seek medical care • Patients should be asked, “Is your health concern today related to a deployment?” during all primary care visits. • If the patient replies “yes,” the provider should follow the Post-Deployment Health Clinical Practice Guideline (PDH-CPG) and sup- porting guidelines available through the DHCC and www.PDHealth.mil

BECK ANXIETY INVENTORY FORM

BECK ANXIETY INVENTORY (BAI)

  • Date Format: MM slash DD slash YYYY
  • The total score is calculated by finding the sum of the 21 items.

    • Score of 0 – 21 = low anxiety
    • Score of 22 – 35 = moderate anxiety
    • Score of 36 and above = potentially concerning levels of anxiety

NEUROPATHIC PAIN FORM

AUTHORIZATION RELEASE OF INFORMATION

AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION

  • Purpose and Laws: This form, when properly completed, permits the release of confidential information about a person receiving services (service recipient) governed and regulated by Title 33, Tennessee Code Annotated. Any information to be released under this form shall be released in accordance with the following confidentiality laws and regulations: Title 33, Tennessee Code Annotated; the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its regulations at 45 Code of Federal Regulations (CFR) Parts 160 and 164; and the federal Confidentiality of Alcohol and Substance Abuse Patient Records and its regulations at 42 CFR Part 2. The records released through this Authorization are protected by the above named confidentiality laws and regulations. A general authorization for the release of medical or other information is NOT sufficient for the purpose of disclosing mental health or alcohol and substance abuse information. Federal rules restrict any use of alcohol and substance abuse information to criminally investigate or prosecute the person to whom the information pertains. Further disclosure of this information to parties other than those designated on this form is expressly prohibited without the express written consent of the person to whom the information pertains.
  • I,
  • Date Format: MM slash DD slash YYYY
  • , authorize
  • To disclose to (Name of person(s) or organization to which disclosure is to be made, and their mailing address):

    Illuminate Ketamine Center, 1936 Brookside Drive Suite E, Kingsport, TN 37660

  • The purpose of the authorized disclosure is to (Specific purpose/use of the disclosure): Facilitate treatment
  • By signing this form, I (the service recipient) understand that if the person or organization designated on this form to receive the information is not a Health Plan or Health Care Provider, some of the released information may no longer be protected by the above named confidentiality laws and regulations. I also understand that signing this Authorization is voluntary, and that I am not required to sign this Authorization in order to get treatment, payment, enrollment, or eligibility for benefits. I also understand that I may revoke this Authorization by doing so in writing at any time; except to the extent that action has been taken in reliance on the information, and that the revocation does not affect any information that was released before the revocation. Even if I do not revoke this Authorization, the Authorization expires automatically one (1) year from the date of signature or as follows:
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • *If a service recipient gives oral consent or signs with an X, this form must be signed by two (2) witnesses:
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • ** If the individual signing this form is acting on behalf of the service recipient, the individual is: (1) the parent, legal guardian, or legal custodian of a service recipient who is under 18 years of age; (2) the conservator or guardian for the service recipient; (3) the guardian ad litem of the service recipient but only for the purposes of the litigation in which the guardian ad litem serves; (4) the attorney-in-fact under a power of attorney who has the right to make disclosures under the power for the service recipient; (5) the executor, administrator, or personal representative on behalf of a deceased service recipient; and (6) the treatment review committee, acting within the authority and scope of Tennessee Code Annotated Section 33-6-107. Appropriate documentation of proof of this individual’s authority to act on behalf of the service recipient must be submitted to the entity being asked to release the information before any information will be released.

ADVERSE CHILDHOOD EXPERIENCE (ACE) QUESTIONNAIRE

Adverse Childhood Experience (ACE) Questionnaire

Finding your ACE Score
  • Date Format: MM slash DD slash YYYY
  • Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
  • Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
  • Touch or fondle you or have you touch their body in a sexual way? or Try to or actually have oral, anal, or vaginal sex with you?
  • No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
  • You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
  • Often pushed, grabbed, slapped, or had something thrown at her? or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
  • Now add up your “Yes” answers. This is your ACE Score