Fill Out The Forms Below

MEDICAL INTAKE FORM

INTAKE FORM

PERSONAL INFORMATION
PATIENT(S)
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
- Male
- Female
Address*
Street Address City State ZIP Code
Home Phone*
Work Phone*
Cell Phone*
RESPONSIBLE PARTY
Responsible Party's SSN*
Address (if different)
Street Address City State ZIP Code
Home Phone (if different)
Work Phone (if different)
Cell Phone (if different)
Patient’s Relationship to Responsible Party (Check One)*
- Self
- Spouse
- Child
- Other
Emergency Contact
Name*
First Last
Phone*
Relationship*
How did you hear about Illuminate Ketamine Center?*
FINANCIAL
Full Name*
Enter initials as a digital signature*
Today's Date*
Date Format: MM slash DD slash YYYY
Insurance Name
ID #
Group #
Insured Person
Relationship
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.
Consent*
I acknowledge that I have read and understand all of the foregoing statements and that my signature below indicates that I agree to abide by all of the above conditions.
Consent
I have received a copy of the Privacy Practices Form.
Consent
I consent to the exchange of treatment information between Illuminate Ketamine Center PLLC and my primary care or mental health provider.
Name*
First Last
Office*
Phone*
Signature
Full Name*
Enter initials as a digital signature*
Today's Date*
Date Format: MM slash DD slash YYYY

HIPPA COMPLIANCE FORM

HIPAA COMPLIANCE PATIENT CONSENT FORM

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.
By signing this form, I understand that: • Protected health information may be disclosed or used for treatment, payment, or healthcare operations. • The practice reserves the right to change the privacy policy as allowed by law. • The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions. • The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. • The practice may condition receipt of treatment upon execution of this consent.
May we phone, email, or send a text to you to confirm appointments?*
- Yes
- No
May we leave a message on your answering machine at home or on your cell phone?*
- Yes
- No
May we discuss your medical condition with any member of your family?*
- Yes
- No
If Yes, please name the members allowed:*
Name*
First Last
Enter your initials to sign electronicly*
Date*
Date Format: MM slash DD slash YYYY

DEPRESSION FORM

BECK DEPRESSION INVENTORY

Name*
First Last
DOB*
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.
1.*
2.*
3.*
4*
5.*
6.*
7.*
8.*
9.*
10.*
11.*
12.*
13.*
14.*
15.*
16.*
17.*
18.*
19.*
20.*
21.*
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

BECK ANXIETY INVENTORY FORM

BECK ANXIETY INVENTORY (BAI)

Name*
First Last
DOB*
Date Format: MM slash DD slash YYYY
1.*
2.*
3.*
4.*
5.*
6.*
7.*
8.*
9.*
10.*
11.*
12.*
13.*
14.*
15.*
16.*
17.*
18.*
19.*
20.*
21.*
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

Neuropathic Evaluation

Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Please use the scale below to tell us how intense your pain is. Check the box of the number that best describes the intensity of your pain*
0=No Pain, 10=The most intense pain sensation imaginable
Please use the scale below to tell us how sharp your pain feels. Words used to describe “sharp” feelings include “like a knife,” “like a spike,” “jabbing” or “like jolts.”*
0=Not Sharp, 10=The most sharp sensation imaginable (“like a knife”)
Please use the scale below to tell us how hot your pain feels. Words used to describe very hot pain include “burning” and “on fire.”*
0=Not Hot, 10=The most hot sensation imaginable(“on fire”)
Please use the scale below to tell us how dull your pain feels. Words used to describe very dull pain include “like a dull toothache,” “aching” and “like a bruise.”*
0=Not Dull, 10=The most dull sensation imaginable
Please use the scale below to tell us how cold your pain feels. Words used to describe very cold pain include “like ice” and “freezing.”*
0=Not Cold, 10=The most cold sensation imaginable("freezing")
Please use the scale below to tell us how sensitive your skin is to light touch or clothing. Words used to describe sensitive skin include “like sunburned skin” and “raw skin.”*
0=Not Sensitive, 10=The most itchy sensation imaginable (“like poison oak”)
Please use the scale below to tell us how itchy your pain feels. Words used to describe very itchy pain include “like poison oak” and “like a mosquito bite.”*
0=Not Itchy, 10=The most itchy sensation imaginable ("like poison oak")
Which of the following best describes the time quality of your pain? Please check only one answer.*
- I feel a background pain all of the time and occasion flare-ups (break-through pain) some of the time.
- I feel a single type of pain all of the time.
- I feel a single type of pain only sometimes. Other times, I am pain free.
Describe the background pain*
Describe the flare-up (break-through) pain*
Describe this pain*
Describe this occasional pain*

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,
Name of Service Recipient*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
, authorize
Name of agency/program making disclosure*
Mailing address of agency/program making disclosure*
Street Address City State / Province / Region ZIP / Postal Code
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 following information (Describe the specific information to be used or disclosed):*
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:
Specify the date, event, or condition of expiration*
Date Format: MM slash DD slash YYYY
Signature of service recipient who is 16 years of age or older **
First Last
Enter your initials to sign electronicly*
Date*
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:
Witness
First Last
Date
Date Format: MM slash DD slash YYYY
Witness
First Last
Date
Date Format: MM slash DD slash YYYY
Signature of individual acting on behalf of the service recipient **
First Last
Enter your initials to sign electronicly*
Date
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.

Fill Out The Forms Below

MEDICAL INTAKE FORM

INTAKE FORM

PERSONAL INFORMATION

PATIENT(S)

RESPONSIBLE PARTY

Emergency Contact

FINANCIAL

PRACTICE POLICIES

Signature

HIPPA COMPLIANCE FORM

HIPAA COMPLIANCE PATIENT CONSENT FORM

DEPRESSION FORM

BECK DEPRESSION INVENTORY

Questionaire

PTSD FORM

PTSD Checklist Civilian Version (PCL-C)

BECK ANXIETY INVENTORY FORM

BECK ANXIETY INVENTORY (BAI)

NEUROPATHIC PAIN FORM

Neuropathic Evaluation

AUTHORIZATION RELEASE OF INFORMATION

AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION

ADVERSE CHILDHOOD EXPERIENCE (ACE) QUESTIONNAIRE

Adverse Childhood Experience (ACE) Questionnaire