New Patient Form

Step 1 of 8

Patient Information:

Please select preferred treatment location:*

What Service(s) are you interested in?*

Check all that apply.

TMS Therapy

Psychiatric Evaluation & Medication Management

How'd you find out about us?*

Please select one option from the dropdown list above.

Do you know which Nashville Neurocare provider you are interested in seeing?*

Please share the name of your healthcare provider:

Name:*

First Middle Last

Address:*

Street Address Address Line 2 City State ZIP Code

Home Phone:

Cell Phone:*

Email*

Please check this box if you do NOT want us to leave a voicemail on the phone numbers listed.

Do NOT leave voicemails.

Date of Birth:*

Age:*

Sex:*

Male

Female

Social Security #:*

Personal Information:

Spouse's Name:

First Last

Spouse's Phone:

Patient Employer/Occupation

Work Phone:

Emergency Contact Name:*

First Last

Emergency Contact Phone #:*

Privacy Practices Acknowledgment Form*

This form, when properly completed, permits the release of confidential information about a person receiving services. Any information to be released under this form shall be released in accordance with HIPAA. The records released through this authorization are protected by HIPAA. Further disclosure of this information to parties other than those designated on this form is prohibited without the written consent of the person to whom the information pertains. 1. I understand that information used or disclosed pursuant to this authorization carries with it the potential for an unauthorized re-disclosure which may not be protected by Federal Privacy regulations. 2. I understand that signing this Authorization is voluntary and refusing to will not jeopardize my right to obtain present or future treatment except where disclosure of the information is necessary for the treatment. 3. I understand that I may revoke this Authorization by doing so in writing at any time; except to the extent that action has already been taken in reliance upon it, 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.

Acknowledge and Accept

Patient Signature:*

Please type your name this will serve as your signature.

Date*

Relationship to Patient

Date

AUTHORIZATION FOR RELEASE OF MENTAL HEALTH RECORDS

(Also known as Protected Health Information)

Patient Name*

Date of Birth*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

I authorize the release of my protected health information:

To: W. Scott West, MD

Name of Your Provider / Provider's Office Name*

Address of Your Provider / Provider Office*

Street Address Address Line 2 City State ZIP Code

Phone of Provider*

Fax of Provider

Information to be released: Intake/Psych eval, Medical records, Diagnoses, Medications w/ doses and durations Purpose of disclosure: TMS Evaluation.

Release of Confidential Information

Acknowledge and Accept - Release of Confidential Information*

Acknowledge and Accept

Patient Signature - Release of Confidential Information

By typing your name in the Patient Signature field below, you Acknowledge and Accept the terms above regarding the Release of Confidential Information, and your typed name will serve as your signature.

Patient Signature:*

Please type your name this will serve as your signature.

Date:*

If you have a SECOND PROVIDER you'd like to include please complete the information below.

This is an OPTIONAL, additional provider information section. Please complete this section accordingly if you'd like to include a SECOND PROVIDER. If you DO NOT have additional information to include, please scroll down and Acknowledge this section of the form to advance to the next page.

I authorize the release of my protected health information:

To: W. Scott West, MD

Name of a SECOND Provider / Provider's Office Name (OPTIONAL)

Address of a SECOND Provider / Provider Office (OPTIONAL)

Street Address Address Line 2 City State ZIP Code

Phone of SECOND Provider (OPTIONAL)

Fax of SECOND Provider (OPTIONAL)

Acknowledge and Accept - Release of Confidential of Information - SECOND PROVIDER

If you DID provided information for a SECOND PROVIDER, please check the box of Acknowledge and Accept.

Acknowledge and Accept

Acknowledge and Accept - I DID NOT include information for a SECOND PROVIDER

If you DID NOT include information for a SECOND PROVIDER, please check the box of Acknowledge and Accept.

Acknowledge and Accept

If you have a THIRD PROVIDER you'd like to include please complete the information below.

This is an OPTIONAL, additional provider information section. Please complete this section accordingly if you'd like to include a THIRD PROVIDER. If you DO NOT have additional information to include, please scroll down and Acknowledge this section of the form to advance to the next page.

I authorize the release of my protected health information:

To: W. Scott West, MD

Name of a THIRD Provider / Provider's Office Name (OPTIONAL)

Address of a THIRD Provider / Provider Office (OPTIONAL)

Street Address Address Line 2 City State ZIP Code

Phone of THIRD Provider (OPTIONAL)

Fax of THIRD Provider (OPTIONAL)

Acknowledge and Accept - Release of Confidential of Information - THIRD PROVIDER

If you DID provided information for a THIRD PROVIDER, please check the box of Acknowledge and Accept.

Acknowledge and Accept

Acknowledge and Accept - I DID NOT include information for a THIRD PROVIDER

If you DID NOT include information for a THIRD PROVIDER, please check the box of Acknowledge and Accept.

Acknowledge and Accept

Notice of Privacy Practices (Medical)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Please Read Carefully*

The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any significant new rights to understand and control how your health information is used. "HIPAA" provides penalties for covered entities that misuse personal health information. As required by "HIPAA", we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations. Treatment means providing, coordinating, or managing health care and related services by one o more healthcare providers. An example of this would include a physical examination. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. The right to inspect and copy your protected health information. The right to amend your protected health information. The right to receive an accounting of disclosures of protected health information. The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of January l, 2011 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing and complaint. Please contact us for more information. For more information about HIPAA or to file a complaint: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, D. C. 20201 (202) 619-0257 Toll-Free: 1-877-696-6775

Acknowledge and Accept

Termination of Treatment*

Patients are not obligated to continue treatment. If you decide to terminate at any time, you are encouraged to discuss your decision to terminate care with your doctor.

Acknowledge and Accept

Nashville NeuroCare Therapy – New Patient Form

Patient Information:

Personal Information:

AUTHORIZATION FOR RELEASE OF MENTAL HEALTH RECORDS

I authorize the release of my protected health information:

Release of Confidential Information

Patient Signature - Release of Confidential Information

If you have a SECOND PROVIDER you'd like to include please complete the information below.

I authorize the release of my protected health information:

If you have a THIRD PROVIDER you'd like to include please complete the information below.

I authorize the release of my protected health information:

Notice of Privacy Practices (Medical)

Emergencies: