Central Texas Mental Health

Patient Demographics and Registration (please print legibly)

Name (Last, First) _________________________________________________________________________

Male Female Other(describe) ________________Date of Birth(MM/DD/YYYY)______/____/______

Marital Status: Single Married Widowed Divorced Other (describe) __________________

Social Security # ______ -_____ -_ ______ Driver’s License # _______________________State__________

Cell ( )_______________ _ Home( )_______ __________ Work ( )______________ __

Mailing Address: __________________________________________________________________________

Apt # _____________ City _______________________________ State ____________ Zip ______________

Email ________________________________________________________

Physical Address (if different from mailing address)

Street__________________________________________________________________________________

City ____________________________________ State ______________ Zip ________________________

Employer _______________________________________________________________________________

Employer Address ________________________________________________________________________

Referred by _____________________________________________________________________________

Primary Care Doctor ______________________________________________________________________

Primary Care Doctor’s Telephone # (if known)___________________________________________________

Primary Emergency Contact Name __________________________________ Tel # ____________________

Secondary Emergency Contact Name ________________________________ Tel # ____________________

Treatment Authorization: I authorize Dr. Michael Musgrove and his representatives to provide me with medical care

and services. Initials: ________

Medical Information: I authorize Dr. Michael Musgrove and his representatives to release any and all information

acquired during treatment to other treatment facilities and providers to whom I am under care on an emergent basis, or

to persons or entities directly responsible for payment of services (if applicable). I further authorize Dr. Musgrove and

his representatives to access electronic prescription history databases for the purpose of my medical care and safety.

Initials: ________

Payment agreement: I agree I am financially responsible for the payment fee(s) for service even though insurers may or

may not reimburse me. Initials: ________

Patient Signature: _________________________________________ Date: __________________________

Printed Name: ____________________________________________

Occupation:______________________________________________________________________________

Education Level:__________________________________________________________________________

Have you had previous psychiatric treatment? Yes No

If yes, where 1. ________________________________________________ When _____________________

2. ________________________________________________ When _____________________

3. ________________________________________________ When _____________________

Additional: ____________________________________________________________________

Have you had previous chemical dependency treatment (detox, etc.) □ Yes □No

1. ________________________________________________ When _____________________

2. ________________________________________________ When _____________________

3. ________________________________________________ When _____________________

Additional: ____________________________________________________________________

Current Psychiatrist _______________________________ How long _________ Last seen ______________

Current Therapist _________________________________ How long _________ Last seen ______________

Current Primary Doctor ____________________________ How long _________ Last seen ______________

Last Physical Examination __________________________ What reason? ____________________________

Why are you seeking help today? ___________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Who do you live with?

Name Relationship Age

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Religion (OPTIONAL): ______________________________________________________________________

Race (OPTIONAL): _________________________________________________________________________

Orientation (OPTIONAL): □ Straight □ Gay/Lesbian □ Bisexual □ Other - Describe ___________________

Patient’s Signature ________________________________________________________________________

Patient’s Name _______________________________________________ Date _______________________

Central Texas Mental Health

Michael Musgrove, MD

1717 North IH-35, Suite 200

Round Rock, Texas 78664

(512) 964-6992 Phone

(512) 610-5679 Fax

Authorization for the Release of and Receipt of information primarily for family members/personal reasons. I hereby authorize Dr. Michael Musgrove and his authorized representatives to disclose and/or obtain my individually identifiable health information as described below, which may include information concerning communicable disease such as HIV/AIDS, mental illnesses, chemical or alcohol dependency, laboratory results, medical history or treatment, or other such related information or materials. I understand this authorization is voluntary and I may refuse to sign. I understand my health care will not be affected if I do not sign this form. Under HIPAA, it is important to know: The Privacy Rule does not require the clinic to obtain a signed consent form before sharing information for treatment purposes. Healthcare providers can freely share information for treatment purposes without a signed patient authorization.

Information to be released (CHECK*)

ALL NONE MEDICATION LISTS LABORATORY RESULTS OFFICE NOTES

Above information can / may be released VERBALLY or in WRITTEN FORM to / from:

Family Members:

________________________________________________________________________________________

Others (CPS, County, Attorney, etc.):

________________________________________________________________________________________

Specific Doctors/Therapists Check box to send your medical chart to the provider(s) below:

________________________________________________________________________________________

I understand this authorization supersedes and revokes any and all authorizations previously on file. This authorization may not

be interpreted as an addition to any previous authorizations on file.

I understand this authorization will expire in 365 days from the date of this authorization unless I specify another date.

I desire this authorization to expire on ______________________ [if applicable].

I understand I may revoke this authorization by issuing a written revocation to the office.

I acknowledge that there is no possible endangerment due to disclosure of my health information.

Patient’s Signature: _______________________________________________________________________

Printed Name: ____________________________________________ Date of Birth: ___________________

Today’s Date :_____________________

Central Texas Mental Health - NOTICE OF PRIVACY PRACTICES

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.

Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other

health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information, usually within 30 days of

your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or

incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications • You can ask us to contact you in a specific way (for example, home or office phone) or to

send mail to a different address.

• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share • You can ask us not to use or share certain health information for treatment, payment, or our

operations. We are not required to agree to your request, and we may say “no” if it would

affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share

that information for the purpose of payment or our operations with your health insurer. We

will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information • You can ask for a list (accounting) of the times we’ve shared your health information for six

years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health

care operations, and certain other disclosures (such as any you asked us to make). We’ll

provide one accounting a year for free but will charge a reasonable, cost-based fee if you

ask for another one within 12 months.

Get a copy of this privacy notice You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. File a complaint if you feel your rights are violated

• You can file a complaint if you feel we have violated your rights by contacting the office

• You can file a complaint with the U.S. Department of Health and Human Services Office for

Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C.

20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission: • Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures - How do we typically use or share your health information? We typically use or share your health information to:

Treat you

We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

Help with public health and safety issues

We can share health information about you for certain situations such as: Preventing disease / Helping with product recalls / Reporting adverse reactions to medications /Reporting suspected abuse, neglect, or domestic violence and preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research. Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations. Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you: • For workers’ compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential

protective services

Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities: • We are required by law to maintain the privacy and security of your protected health

information.

• We will let you know promptly if a breach occurs that may have compromised the

privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you

a copy of it.

• We will not use or share your information other than as described here unless you tell

us we can in writing. If you tell us we can, you may change your mind at any time. Let

us know in writing if you change your mind.

Changes to the Terms of this Notice - We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, on our web site, and we will mail a copy to you.

Central Texas Mental Health 1717 N IH 35 Ste. 200 Round Rock, TX 78664 (512) 964-6992

Central Texas Mental Health

1717 N IH 35, Suite 200

Round Rock, TX 78664

P (512) 964-6992 | F (512) 610-5679

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY

PRACTICES

*YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT*

I, ____________________________________ have received a copy of the Notice of Privacy

Practices for Central Texas Mental Health.

_____________________________________________________________

Print Patient’s Name

_____________________________________________________________

Print Name of Person Responsible (if patient is under 18)

______________________________________________________

Signature of Adult

______________________________________________________

Today’s Date

Office Use ONLY

We attempted to obtain written Acknowledgement of Receipt of Notice of Privacy Practices, but

acknowledgment could not be obtained because:

______ Individual refused to sign

______ Communication barriers prohibited obtaining acknowledgement

______ An emergency situation prevented us from obtaining acknowledgement

______ Other (please specify)______________________________________________________

Staff Name Staff Signature Date

Central Texas Mental Health - Office Policies (2/21/20)

We appreciate the opportunity to serve you and we have developed office polices that facilitate the delivery and quality of care to all of our patients. **Please keep this document for your records.

Appointments

1. In consideration of all patients, individuals who arrive more than 5 minutes late may need to reschedule their appointment. At the discretion of staff, this policy may be waived on a case-by-case basis and/or allow an abbreviated visit. If you are running late, please let us know as soon as possible.

2. Cancellations of scheduled appointments should be made with 48* hours notice, minimum to avoid fee

3. If a scheduled appointment is cancelled or rescheduled with less than 24* hours of notice, that will be considered a late cancellation.

4. The no-show fee is $25. Late cancellations will be subject to a $15 fee.* (*separate fees for TMS visits)

5. Three no-shows or late cancellations in a 12 month period of time may result in the termination of our professional relationship.

6. Although staff may regularly confirm appointments 1-2 days prior, it is the responsibility and an expectation of the patient to attend follow-up appointments. Follow-up appointments will be typically scheduled after each visit in order to foster continuity of care and availability.

7. While staff and clinicians are normally available by phone, patients are encouraged to make or move up an appointment when a complaint or problem occurs with regard to their mental health. Please reserve telephone inquiries to clinicians for issues that can be reasonably managed by phone, else scheduling an appointment is recommended. There may be a modest charge for evaluation or management done over the phone if call length is 5 minutes or longer.

8. It is the responsibility of the patient to inform us of any changes in insurance, or other demographic information (address, telephone numbers, emergency contacts, releases of information, email). Please review this information at least annually.

9. Please do not bring children to the appointments that cannot sit in a waiting room alone safely and quietly. We reserve the right to refuse service if we deem the child too young to sit in the waiting room alone.

10. We do not see both spouses at our practice as patients, to avoid a conflict of interest in case of separation, divorce or custody issues. Please ask our receptionist for a list of other providers if the need arises.

Payments

1. Payments, co-payments and balances are due at time of service.

2. We reserve the right to discontinue our professional relationship if a balance is not resolved.

3. Although our staff may assist, the patient is responsible for being aware of current insurance coverage, including deductibles, co-pays, need for pre-certification, annual visit limits (and how many remaining), out of network benefits (if applicable).

4. If a third party payer (insurance, or other sponsor) fails to resolve the balance, the patient will be responsible. If limits of coverage are exceeded, the patient will be responsible for the full amount. The level of care and frequency of visits as determined by your clinician may exceed what your insurance plan may cover in some instances.

5. Currency bills over $100 may not be accepted, due to lack of change. Credit and debit cards, cash, checks accepted.

6. There is a $35 dollar charge for returned checks. $25 for 3rd party Medical Records requests and $6.50 for patients' request. $5 for replacement of lost or expired prescriptions, please take care of them in an appropriate manner.

Forms and Refill Requests It is the responsibility of the patient to have their pharmacy fax in a refill request with 48-72 hours anticipation (before medicine runs out) for timely processing. Five business days is recommended. Call your pharmacy before calling the clinic, this process may reduce the chance of error. Be sure to verify the pharmacy has our correct contact information and fax number and aware we are on E-prescribe.

1. Texas law requires patients to be under medical supervision when taking controlled medication. You may be required to see a clinician before your medicine is refilled if you have missed your prior appointment(s) and/or in order to determine medical necessity.

2. If a patient is going to run out of medicine within 48 hours, or has already run out (late refill request), the

patient may call the office to request the clinician to call it in to the pharmacy.

3. Forms (including disability, FMLA and other reports) may require a separate appointment in order for the

clinician to gather information specific to the form from the patient. For Disability Forms, $95 fee is typical for

each forms research, completion and delivery. The fee for FMLA Leave forms is $25. Our philosophy and goal

is to return employees on leave or disability back to normal functioning and work status as soon as possible,

this may include recommendation for Intensive Outpatient (IOP) during leave.

4. C-II medications such as stimulants require as a general rule an appointment for refills. These prescriptions have an expiration of 21 days, including transit time and processing at mail-order pharmacies. If the patient loses a prescription or med bottle, lets a prescription expire, or increases the dose, an appointment may be required to monitor compliance and medical necessity with these more controlled CII medications before a new prescription is issued. Monitoring appointments of patients taking C-II prescriptions as a rule is no less often than quarterly. Lost or expired scripts will incur a $5 fee to replace.

After-hours Resources

1. Services will be provided to the patient within normal business hours.

2. In case of an emergency, the patient may call 911 (for medical or psychiatric emergencies), 472-HELP (suicide hotline for Travis Co.) or may go to a local Emergency Room or psychiatric hospital (or a combination of the above.) Please see our website Resources at centexmh.com

3. Psych Hospitals: Shoal Creek Hospital (512) 324-2000 Austin Lakes Hospital (512) 544-5253

4. Urgent Care Centers (Nextcare etc.) can be a resource for short-term refills (bring your empty bottle) and

Pharmacies can dispense a 3 day (a.k.a. “loaner”) supply at their discretion.

Compliance

1. It is our hope and expectation that patients are motivated to improve their mental health.

2. It is the responsibility of patients to comply with agreed-upon treatment plans and recommendations from the clinician (treatment alliance and therapeutic relationship).

3. Our office uses Mentegram Psychological Testing as an aid in your treatment. You have the right to refuse this (and any other treatment) however it may be considered noncompliance with medical recommendations.

4. Repeated instances of non-compliance (failure to get labs, failure to follow-up with therapists, self-medicating, and others) will be considered potentially hazardous and a violation of office policy.

5. Our providers may administer oral/blood/urine drug screening in order to monitor compliance and appropriateness of certain medications. Consent is voluntary, but refusal may limit medication options your provider can prescribe.

6. Treatment is based on the informed consent of the patient. If you have any questions or concerns regarding medications or other aspects of treatment, please query your provider. Do not consent to any medication or other intervention before considering yourself adequately informed.

Hygiene

1. It is the responsibility of the patient to groom and dress appropriately for a medical appointment. Although rare, repeated instances of inappropriate dress or hygiene may be considered a violation of office policy. Do not show for your appointment intoxicated.

Behavior

1. We understand that patients experience many difficulties as a result of mental health problems or other reasons and we strive to provide the best outpatient service for our patients. However, if at any point staff or clinicians feel threatened by an individual, this may be cause for immediate termination of our professional relationship. Threatening behavior includes (but is not limited to) direct or indirect threats towards staff or other patients, lewd behavior, verbal abuse, yelling or physically damaging property. Please be civil at all times.

2. Deliberately misleading staff or clinicians may be grounds for termination of our professional relationship, depending on the circumstance.

Confidentiality

1. The clinic understands the need to keep your matters confidential, and we will act in good-faith to maintain your matters private. Please use caution in leaving us home or work numbers to call you back, as leaving a message or conversing there may jeopardize your confidentiality. Please keep you contact information current in cases of moving, divorce, job change, or phone change.

2. Staff or physicians may require a release in order to speak to family members or other providers, unless the clinic believes in good faith there is an emergency and it serves your best interests (principle of beneficence). Please ask the receptionist for releases for anyone you would like to have access to your information ahead of time. Review and update your Release form at least annually as well as your Contact Information.

3. Certain 3rd

party payers, labs, courts and other entities industry may need access to some of your protected health information (PHI). Please see HIPAA statement. While patient confidentiality is protected and highly valued, exceptions to physician-patient confidentiality do exist pursuant to state and federal law.

*Unless otherwise specified, “hours” refers to business hours of the clinic. Severe or repeated violations of office policy may result in a discontinuation of our professional relationship. If the patient doubts the validity of violation, he/she can contact our office to discuss. You reserve the right to end our professional relationship at any time. We look forward to serving you!

This Office Policy may be updated in the future without notice; however a current copy can be requested at our office, by mail or fax, free of charge. If any policy is in conflict with state, local or federal law, that policy or portion of that policy will be considered null and void. Central Texas Mental Health is a DBA (”doing business as”) of Round Rock Mental Health PLLC, formerly known as Round Rock Mental Health PA.

Central Texas Mental Health Notice of Receipt of Office Policies

Policies can be found stapled, at the back of this paperwork—Please ask for a copy of these policies from the receptionist, if you do not have one

I, _________________________________ have received a copy of Central Texas Mental Health’s Office Policies (effective 2/21/20). __________________________________________ __________________________ Signature Today’s Date __________________________________________ __________________________ Printed Name Date of Birth

Controlled Substances Therapy Agreement

The purpose of this agreement is to protect your access to controlled substances and protect our ability to prescribe to you. Certain medications for concentration, anxiety and sleep have the potential for abuse or diversion. Accountability is necessary as per governing bodies. For this reason, the following policies are agreed to by you, the patient, as consideration for, and a condition of, the willingness of the providers at CTMH to consider the initial and/or continued prescription of controlled substances to treat your mental health diagnoses.

1. All controlled substances in a class should be prescribed from the same medical practice.

2. All controlled substances should be obtained at the same pharmacy, when possible.

3. You are expected to be proactive and inform our office of any new, recent or current controlled medications prescribed or non-prescribed. This applies to recreational and/or illegal substances.

4. The prescribing provider has permission to discuss all diagnostic and treatment details with

dispensing pharmacies and other professionals who provide your health care. This includes accessing physical and electronic medicine prescription histories online.

5. You may not share, sell, or otherwise permit others to have access to these medications. Care for

the safety of your medication and always keep it in the original container from the pharmacy. 6. These medications should not be stopped abruptly, as an abstinence syndrome may develop.

7. Initial or subsequent oral, urine or blood toxicology may be requested, and your cooperation may be

required for ongoing treatment with certain controlled medications. Consuming illegal or non-prescribed substances (aka “street drugs”) may be grounds for discontinuing controlled substances and/or discontinuing our professional relationship.

8. Early refills may not be approved. Please discuss with your office any extenuating circumstance.

9. Refills are contingent upon scheduling and keeping regular appointments.

10. It is understood that non-adherence to these policies may result in cessation of therapy with the

controlled medication and potentially your therapeutic relationship with our practices. Please attest “I have read, understood and agree to the Controlled Substances Agreement.” _______________________________________________ ___________________ Patient Name Patient DOB _______________________________________________ ___________________ Patient Signature Date

Central Texas Mental Health 1717 North IH-35, Suite 200 Round Rock, Texas 78664

(512) 964-6992 tel. (512) 610-5679 fax

Central Texas Mental Health

1717 N. IH-35 Ste 200

Round Rock, TX 78664

512-964-6992

centexmh.com

Medical Chart Photo Consent Form

I hereby consent to a photograph (drivers’ license style) being taken of me, or to provide one for the

exclusive purposes of adding the photo to my digital medical chart. This serves 2 purposes:

1) Serve as a secondary identifier to avoid office confusion with patients with a similar name.

2) Serve as a memory prompt for providers and staff to remind them who you are.

You may decline the photo consent but is not recommended for the above safety reasons.

I consent to a photo taken, or provided to the office:

Name ___________________________________________________________________________

Date of Birth _______________________________ Today’s Date ________________________