Patient Information Form — Dr. Boris A. Khaimov, D.O.

Please complete all sections below as thoroughly as possible. Fields marked * are required. All information is held in confidence per the terms described at the end of this form.

Insurance Information

Primary Insurance

Policy #

Name of Insured

Date of Birth*

Name of Employer

Presenting Problem

Please describe your reasons for seeking counseling. Include date/month the problem started. Any ideas about hurting self/others?*

Was there an event which made issues or problems surface?*

Yes No

Impairment Level

Please rate each category twice: once for how current symptoms are affecting you now, and once for the impairment you anticipate at discharge.

Current Symptoms

Please indicate how current symptoms have affected your level of impairment in each category below.

Current Symptoms — Total Score

Calculated automatically from your selections above.

Anticipated Impairment at Discharge

Please indicate your anticipated level of impairment in each category at discharge.

Anticipated Impairment at Discharge — Total Score

Calculated automatically from your selections above.

Medical History

Please list any prescription and/or over the counter medications you currently use (include name, dosage and frequency)*

Please list any conditions, past or present, that you have been treated for*

When was your last physical examination?

What was the doctor's name?

Doctor's phone number

Family History

Describe any medical or psychiatric conditions of your parents or siblings.

Mother

Father

Sister(s)

Brother(s)

Habits

Include in your answer: amount currently using, most ever used, and allergies.

Coffee (cups per day)

Cigarettes (packs per day)

Alcohol

Psychiatric History

Have you received psychiatric or psychological treatment of any kind before?*

Yes No

If you checked yes above, what type of care did you receive

Inpatient Outpatient Both

When were you in treatment? (include dates)

Where were you in treatment?

How long were you in treatment?

Who was your therapist or doctor?

Did your doctor prescribe medicine at that time?

Yes No

Substance Abuse History

Have you ever abused drugs or alcohol?*

Yes No

If yes, please describe the substance(s), amount(s), frequency(s), when? (first use, last use)

If yes, have you ever received substance abuse treatment of any kind before?

Yes No

Do you have a history of blackouts, seizures or withdrawal symptoms?

Yes No

Please describe anything else you would like Dr. Khaimov to know:

Additional Questions

Have any of your blood relatives been diagnosed as "manic depressive" or as having "bipolar disorder"?*

Yes No

Have you ever had far more energy than usual, slept very little, and engaged in activities that may have been risky or dangerous?*

Yes No

Mood Disorder Questionnaire (MDQ)

Section 1

Has there ever been a period of time when you were not yourself and...*

If you answered Yes to more than one of the questions above, please continue to Section 2 below.

Section 2 — Did any of the situations you said yes to ever happen during the same period of time?

Yes No

Section 3 — How much of a problem did any of these situations cause you: i.e., being unable to work; having family, money or legal problems; getting into serious arguments or fights?

It was no problem It was a minor problem It was a moderate problem It was a serious problem

Confidentiality

All information between doctor and patient is held strictly confidential unless:

The patient authorizes release of information with his/her signature;
The patient presents a physical danger to self;
The patient presents a danger to others;
Child/Elder abuse is suspected.

In cases 3 and 4, we are required by law to inform potential victims and legal authorities so that protective measures can be taken.

Financial Terms

Upon verification of health plan/insurance coverage and policy limits, your insurance carrier will be billed for you and your Provider will be paid directly by the carrier. The patient will be responsible for any applicable deductibles and co-payments. If you are not eligible at the time services are rendered, you are responsible for payment. For those patients without health plan/insurance coverage, payment arrangements are to be made prior to your first visit.

Cancelled/Missed Appointments

A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with less than 24 hours notice, the patient will be billed according to the scheduled fee of $175.00.

Appeals and Grievances

I acknowledge my right to request reconsideration in the case that outpatient care (number of visits) is not authorized (Appeal). I understand that I would request an Appeal through my Provider and that I risk nothing in exercising this right. I also acknowledge that I may submit a Grievance to the Provider or Clinical Group Administrator at any time to register a complaint about any aspect of my care. If I am not satisfied with the response I receive, I may submit the Grievance directly to VBH.

Consent for Treatment

I further authorize and request that Dr. Boris Khaimov carry out psychological examinations, treatments and/or diagnostic procedures which now or during the course of my care as a patient are advisable. I understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement. I also understand that while the course of therapy is designed to be helpful, it may at times be difficult and uncomfortable.

Release of Information

I authorize the release of information for claims, certifications/case management/quality improvement and other purposes related to the benefits of my Health Plan. Releases of information to providers, family or anyone other than the above mentioned, requires a separate form.

Patient Name*

Patient/Parent or Guardian Signature*

If patient is under the age of 18, a parent or guardian must sign for consent.

First Name*

Last Name*

Signature preview

Your signature will appear here as you type

By typing your name above, you are signing this form electronically.

Date*

I understand and agree to all of the above information.

Your responses are sent securely to the practice. Nothing is stored in this browser.

Thank you

Your patient information form has been received. Our office will contact you before your appointment if anything further is needed.