We do not offer General Psychiatry Services, commonly known as Talk Therapy, or Medication Management.

New Patient Form

Nashville NeuroCare Therapy – New Patient Form
  • Patient Information:

  • Personal Information:

  • Emergency Contact Information:

  • Electronic Mail (EMAIL) Policy

    We will file each visit with your primary insurance company. Please provide us with all information necessary to bill your insurance company. Please make sure we have current and correct information. Regardless of the status of your insurance, you are responsible for any balance. Payment is expected at the time of service unless prior arrangements are made with our billing department. Payment may be made by cash, check or credit card (Visa, Master Card, American Express or Discover). Any balances will be due upon receipt of our monthly statement. Accounts over 30 days are subject to a late fee. We are happy to file insurance for you; however, we cannot guarantee payment from them.
  • Please type your name this will serve as your signature
  • Payment Policy

    Payment may be made by check or credit card.
  • Appointment Charges / Cancellation Policy

    We do not overbook appointments and appointments made are reserved for the patient. We require a 24-hour cancellation notice. Patients will be charged the full session rate if they do not cancel an appointment within the 24-hour time frame. Patients will also be charged the full session rate if they fail to keep their appointment on the day it is scheduled. Insurance does not cover missed or canceled appointments. If you need to change or reschedule an appointment, please call our office as soon as you can so we can accommodate other patients who wish to be seen.
  • *For your convenience, we are able to keep a credit card on file to charge at your appointments. If you would like to use this service, please fill in the information below.
  • Date Format: MM slash DD slash YYYY
  • Please type your name this will serve as your signature.
  • Date Format: MM slash DD slash YYYY
  • Please type your name this will serve as your signature.
  • Date Format: MM slash DD slash YYYY
  • Insurance Policy:

    Nashville NeuroCare Therapy/neuroCare Centers of America is contracted with Medicare, BCBS TN, Humana, Beacon, Aetna, and United Behavioral Health/Optum. We will file your insurance for you and you will be responsible for any deductible or copay as determined by your insurance company.
  • For all other insurance companies that Nashville NeuroCare Therapy is out of network with we are happy to file your insurance for you, however, payment will be due in full at the time of service.
  • Payment Policies:

    Payment for TMS treatment is due in full at the beginning of treatment.
  • Emergencies:

    To reach your doctor after office hours call the main office at 615-465-4875 and leave a voicemail, your doctor will be contacted and return your call within 24 hours. If you are experiencing an emergency and cannot wait, please call 911.
  • Guarantor Information (complete only if the patient is NOT paying for the bill):

  • Please type your name this will serve as your signature.
  • Date Format: MM slash DD slash YYYY
  • 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. Consent
  • Please Type Name
  • Date Format: MM slash DD slash YYYY
  • 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 REVIEW IT 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
  • Privacy Practices Acknowledgment Form

    I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: • conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. • obtain payment from third party payer. • conduct normal healthcare operations such as quality assessments and physician certifications. I have been informed by you of your notice of privacy practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such notice of privacy practices prior to signing this consent. I understand that this organization has the right to change its notice of privacy practices from time to time and that I may contact this organization at any time to obtain a current copy of the notice of privacy practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on the consent.
  • Please type your name as it will serve as your signature.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Medical Conditions and Medications

  • Date Format: MM slash DD slash YYYY
  • Current Medication Information

  • Patient Health Questionnaire- 9

    (PHQ-9)
  • Over the last 2 weeks, how often have you been bothered by any of the following problems? Below the answers have a value of 0 - 3. A staff member will total up your score for you.
  • A staff member will total up your score for you.

  • Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. No permission, is required to reproduce, translate, display or distribute.
  • Generalized Anxiety Disorder-7

    (GAD-7)
  • Over the last 2 weeks, how often have you been bothered by any of the following problems?
  • A staff member will total up your score for you.

  • AUTHORIZATION FOR RELEASE OF MENTAL HEALTH RECORD

    (Also known as Protected Health Information)
  • I authorize the release of my protected health information:

    To/From: W. Scott West, MD
  • AUTHORIZATION FOR RELEASE OF MENTAL HEALTH RECORD

    Information to be released: Intake/Psych eval, Medical records, Diagnoses, Medications w/ doses and durations Purpose of disclosure: TMS Evaluation.
  • 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.
  • Please type Name this will serve in place as your signature.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

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