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Patient Intake Form

Patient Intake Form

Personal Details Fields

Contact Preferences

*Reminder: Missed appointments are subject to a $50 cancellation fee.

Emergency Contact

Medical Information

Insurance Information

Patient Agreement

Payment for Services

I agree that I am required to pay in full for the services rendered by this office, regardless of whether my insurer covers such expenses. I understand that if there is a lapse in payment exceeding a 90-day period, my account will be referred to collections and I will be discharged from care.

Assignment of Insurance Benefits

I authorize direct payment to this office of any insurance benefits otherwise payable to me for my treatment. I acknowledge that I remain financially responsible for charges not covered by my insurance provider.

Managed Care Plan

I understand that it is my responsibility to know and understand my managed care plan. I understand that this office will only file insurance claims if I provide proper information and a copy of my current insurance card.

Termination Policy

I understand that this office has the right to discontinue services at any time for reasons including failure to attend appointments, failure to cooperate with treatment, or failure to comply with prescribed treatment requirements.

Prescriptions

I understand that it is my responsibility to track refill needs and that this office requires a seven day notice for refills of controlled or pre-authorized medications.

Cancellation Policy

I agree to and understand that there is a $50 charge for existing patients ($75 for new patients) for missed appointments or cancellations with less than 48 hours notice. If I am more than 10 minutes late, my appointment may be canceled and charges will apply.

Release of Information

I authorize this office to disclose necessary information to any person or corporation that may be liable for payment for services rendered to me.

Informed Consent

I am aware that I have the right to know all risks, benefits and treatment alternatives before consenting to any treatment, and that I have the right to refuse treatment.

Arbitration

I understand that any dispute as to medical malpractice will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process.

Final Signature

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Address

1333 Howe Ave Suite 107, Sacramento, CA, 95825

Email Us

info@ipsychiatry.net

Phone

916-333-1511
Fax

916-237-0879

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Our vision is to eliminate barriers that prevent patients and families from receiving psychiatric care due to geographical location, psychiatrist shortage, cost limitations, or stigma associated with getting mental health help.

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