New Patient Forms

Name(Required)

First Last

Todays Date(Required)

Date of Birth(Required)

Sex(Required)

Male

Female

Social Security Number(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone(Required)

Cell Phone (Text Reminders)(Required)

Work Phone(Required)

Email(Required)

Name of School (If In School)(Required)

Grade(Required)

Employer(Required)

Occupation(Required)

Phone(Required)

Work Address(Required)

Street Address Address Line 2 City State ZIP Code

Insurance

Primary Insurance Carrier Name(Required)

Subscriber Information Name(Required)

Member ID #(Required)

Relation To Subscriber(Required)

Self

Spouse

Child

Secondary Insurance Carrier Name(Required)

Subscriber Information Name(Required)

Member ID #(Required)

Relation To Subscriber(Required)

Self

Spouse

Child

I understand that all psychiatric evaluations or screenings in preparation for surgery will not be filed with insurance and are subject to private payment by the patient at the time of the evaluation/screening.(Required)

Yes, I understand.

Appointed Pharmacy

Pharmacy(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Allergies To Medications(Required)

List All Medicines Currently Taking(Required)

Include the amount you are taking at each dose and how often per day you take each medication. I.E. Asprin 1mg twice per day.

Family Physician(Required)

Emergency Information

Name(Required)

First Last

Relationship(Required)

Phone(Required)

Spouse/Partner Name(Required)

First Last

Phone(Required)

Signature of Patient or Guardian(Required)

First Last

24 Hour Cancellation and No Show Appointment Policy

Novas provides a courtesy call to remind patients of their appointments. It is the responsibility of the patient to call or cancel within 24 hours of the scheduled appointment to avoid a no-show charge of $50.00 for follow-ups and $100.00 for new patients to be paid in full by cash or credit card before the next visit can be scheduled. If your contact information changes between visits, it is the responsibility of the patient to contact our office to avoid any fees. Any outstanding fees must be paid before seeing ANY provider within Novas. There are circumstances that exceptions may be made to this policy upon the discretion of the provider. After two (2) no-show appointments, the patient will be given a warning of discharge for noncompliance up to the third (3) no-show. This policy is in place out of respect for our psychiatrists and outpatients. Cancellations with less than 24-hour notice are difficult to fill. By giving last minute notice or no notice at all, you prevent someone from being able to schedule into the time slot.

Patient Initials(Required)

Signature of Patient or Guardian(Required)

First Last

Patient HIPAA Acknowledgment and Consent Form

Name(Required)

First Last

Date of Birth(Required)

Patient Initials(Required)

Consent(Required)

I agree to the release of information policy.

I hereby permit practice and the physicians or other professionals involved in the inpatient or outpatient care to release healthcare information for purposes of treatment, payment, or healthcare operations.

• Healthcare information regarding a prior admission(s) at other HCA affiliated facilities may be made available to subsequent HCA affiliated admitting facilities to coordinate Patient care or for case management purposes. Healthcare information may be released to any person or entity liable for payment on the Patient's behalf in order to verify coverage payment questions, or for any other purpose related to benefit payment. Healthcare information may also be released to my employer's designer when the services delivered and related to a claim under worker's compensation.

• If I am covered by Medicaid or Medicare, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers for payment of a medicare claim or to the appropriate state agency for laboratory reports operative reports, physicians progress notes, nurse's notes, consultations, psychological and/or psychiatric reports\ drug and alcohol treatment and discharge summary.

• Federal and state laws may permit this facility to participate in organizations with other healthcare providers, insurers, and/or other healthcare industry participants and their subcontractors in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not be limited to improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my information, aggregating and comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member of one or more such organizations. This consent specifically includes information concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical dependency conditions, and/or infectious diseases including, but not limited to bloodborne diseases, such as HIV and AIDS.

Patient Initials(Required)

Disclosures to Friends and/or Family members

DO YOU WANT TO DESIGNEE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM? I give permission to my Protected Health Information to be disclosed for purposes of communicating results, finding, and care decisions to the family members and others listed below: Patient may revoke or modify this specific authorization and that revocation or modification MUST be in writing

Name

First Last

Relationship

Phone

Name

First Last

Relationship

Phone

Name

First Last

Relationship

Phone

HIPAA Notice of Privacy Practices

This notice describes how medical information may be used and disclosed and how you can get access to this information. Please review carefully.

This notice of privacy practices describes how we may use and disclose your protected information (PPHD to carry out treatment, payment, or healthcare operation and for other purposes that are permitted or required by law It also describes your right to access and control your protected health information. "Protect Health Information" is information about you or your future physical or medical health or condition and related to health care services.

Use and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by your provider, Our office staff and others outside of our office that are involved in your case and treatment for the purpose of providing healthcare services to you, to pay your healthcare bills, to support the operation of the physicians' practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party. For example, your protected health information may be provided to a provider to whom you have been referred to ensure that the provider has the necessary information to diagnose and treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for healthcare services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose your protected health information in the following situation without your authorization. These situations include: as required by law Public Health issues, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Military Activity and National Security, Worker's Compensation. We must make disclosures to you and when required by the Secretary of the Department of Health and Human Service to investigate or determine our compliance with the requirements of Section 164.500

Other permitted and required uses and disclosures: Will be made only with the consent, authorization, and opportunity to reject unless required by law. You must revoke this authorization at any time in writing except to the extent that your provider or the provider's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your rights: You have the right to review your protected health information. Under federal law, however, you may not review or copy the information compiled in reasonable anticipation of, or use in a civil, criminal, or administrative action or proceeding and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected information for the purposes of treatment, payment, or health operations.

Your provider is not required to agree to a restriction that you may request. If your provider believes it is in your best interest to permit, use and disclose of your protected health information, your protected health information will not be restricted. You then have the right to use another healthcare professional.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

You may have the right to have your provider amend your protected health information. If we deny your request for amendment, you have the right to file a statement with us and we may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy officer:

HIPPA Privacy Officer

215 Rue Fontaine

Lafayette, LA 70508

Or call us at: (337)889-3682

We will not retaliate against you for filing a complaint. This notice was published and becomes effective or/or before February 2012' We are required by law to maintain the privacy of and provide with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPPA compliance officer in person or by phone

Consent for Treatment: I authorize Novas staff and attending providers to render to the patient all customary care, therapy, treatment, considered advisable, including emergency treatment and transportation to another facility if necessary.

The undersigned acknowledges that the patient is under the care of a provider and Novas is not liable for any act or omission in the following the instructions of said provide(s). The undersigned recognized that certain healthcare professionals furnishing services to patient, including but not limited to. Nurse Practitioners, and./or social workers that are independent contractors and or not employees or agents of Novas. The undersigned further recognizes that the patient is responsible for any health insurance deductible, federally mandated co-insurance, and non-covered charges for the provider(s).

Consent for Release of Information: I authorize Novas to release all patient information, including specific information regarding diagnosis, treatment, and prognosis with respect to any physical, psychiatric, or drug/alcohol-related condition for which patient is being treated, including treatment for Acquired Immune Deficiency Syndrome (AIDS), while a patient of Novas to any insurance company, and/or third-party payors, or representative providing coverage for services, to any appropriate representative ofNovas including, but not limited to employees (as applicable by HtrPA laws, attending providers, other healthcare professionals or organizations. This information may not be released to any other person or entity unless the undersigned so authorizes

I acknowledge that such disclosure shall be limited to information that is responsible necessary for the billing of the legal or contractual obligations of the person(s) or entities to which information is released. I further authorize, Novas to release information for the purpose of obtaining pre-authorization for treatment to release the information to medical review agencies, and/or third-party payors providing coverage or having responsibility for these services.

Guarantee of Payment/Financial Responsibility: I, hereby agree to guarantee the payment of the bill for services rendered by Novas. I agree whether signing as guarantor or as a patient, that in consideration of the services to be rendered to the patient, to be hereby jointly and individually obligated to pay the account in accordance with the regular rates and terms of Novas. I agree that I am responsible for any health insurance deductible, federally mandated co-insurance, and non-covered charges. Should the account be referred for collection by an attorney or collection agency, the undersigned agree(s) to pay all attorney's fees and other reasonable collection costs and charges that are necessary for the collection of any amount(s) not paid when due.

Assignment of Insurance Benefits: In consideration of medical services rendered or to be rendered by Novas to the extent permitted by law. I hereby (I) Irrevocable assign, transfer and set over the Novas (lI) all of my rights, title, and interest to medical reimbursement, including, but not limited to, (III) the right to designate a beneficiary, add dependent eligibility, and (IV) to have an individual policy continued or issue in accordance with terms and benefits under any insurance policy subscription certificate or other health benefit indemnification agreement otherwise payable to me for those services rendered by the cooperation during the pen ency of the claim. Such irrevocable assignment and transfer shall be for the recovery on said policy and policies of insurance, but shall not be construed to be an obligation of cooperation to pursue any such right of recovery. I hereby authorize the insurance company or companies third-party payor(s) to pay directly to Novas all benefits due for services rendered.

Acknowledge of Receipt of HIPPA Privacy Practices: I individually or as the personal representative of the patient, acknowledge that I was given a copy of Novas Notice of Privacy Practices that describes how medical information about me may be used and disclosed, and how I can get access to this information.

Patient Name(Required)

First Last

Signature of Patient or Guardian(Required)

First Last

Date(Required)

Informed Consent for Tele-Medicine Services

Patient Name(Required)

First Last

Date(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

I understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider to deliver services to an individual when he/she is located at a different site than the provider, and hereby consent to Novas providing healthcare service to me via telemedicine.

I understand that the law protects the privacy and confidentiality of medical information that also applies to telemedicine. As always, your insurance carrier will have access to your medical records for a quality review audit. Should need medical records, please contact our office at (337)889-3682

I understand that I will be responsible for any co-payments or co-insurances that apply to my telemedicine visit. In the event of a technology failure, please call our office to schedule an appointment. If it's an emergency, please go to the local hospital or call our office during business hours at (337)889-3682

I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent verbally or in writing at any time by contacting:

Melissa Guilbeau, PMHNP License #AP04767

Katie Porche, PMHNP #APRN208520

Kathryn Hebert, PMHNP #AP06122

As long as this consent is in force (has not been revoked) Novas may provide health care services to me via telemedicine without the need for me to sign another consent form.

Signature of Patient or Guardian(Required)

First Last

Date(Required)

Credit Card Authorization Form (Keep on File)

This form is for you to supply Novas with credit card information to keep on file for the payment of all services and fees. Fees can include but are not limited to: Office visit fee Co-payment fee Late or no show fee as per office policy Lab fee Office form request fee Request form record fee. A new form must be completed for each card kept on file. Novas accepts Visa, Discover, Mastercard, American Express.

Card Type(Required)

Visa

Mastercard

Discover

American Express

Name on Card(Required)

First Last

Card Number(Required)

Card Expiration Date (mm/yy)(Required)

CV Code (# on the back of the card)(Required)

Cardholder Signature(Required)

First Last

Medical Records Release

Name(Required)

First Last

Date(Required)

Name (other than patient)(Required)

First Last

Relationshipship(Required)

Phone(Required)

Records are to be sent to:(Required)

Records are to be sent from:(Required)

Physician's Office(Required)

Physician's Specialty (if applicable)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Fax

Records are to be sent to:(Required)

Yes

No

Check yes if you want a copy of your medical records mailed to you. Enter outside provider's information if you would like one of the providers chosen above to send your medical records to another provider.

Name

First Last

Physician's Specialty (if applicable)

Address

Street Address Address Line 2 City State ZIP Code

Phone

Fax

Please send the following:

Authorization: I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDS information. I have read the above and authorize the disclosure of the protected health information as needed.

Signature of Patient/Representative(Required)

First Last

Date(Required)

Relationship to Patient(Required)

*When obtaining records from this office for personal reasons or permanent transfer there is a nominal copying fee. If it is necessary** to obtain your records from storage, a flat rate of $25 + copying fees will be charged.

LET'S TALK

Start Your Journey To Better Mental Health

Insurance

Appointed Pharmacy

Emergency Information

24 Hour Cancellation and No Show Appointment Policy

Patient HIPAA Acknowledgment and Consent Form

Disclosures to Friends and/or Family members

HIPAA Notice of Privacy Practices

Informed Consent for Tele-Medicine Services

Credit Card Authorization Form (Keep on File)

Generalized Anxiety Disorder 7-item (GAD-7) scale

Scoring

Patient Health Questionnaire (PH0-9)

The Mood Disorder Questionnaire

Medical Records Release

Let’s Talk

Lafayette

New Iberia

Office Hours

Contact Us

215 Rue Fontaine, Lafayette, LA 70508

605 S Lewis St New Iberia, LA 70560

Phone: (337) 889-3682

Fax: (337) 806-9339

Mon - Thurs: ( 8am - 4:30pm ) Fri: ( 8am - 12pm) Sat & Sun: CLOSED

We Treat

Book Appointment

LET'S TALK