Patient Registration Forms

Please read carefully and complete the following 6 forms. All information is kept secure and is only accessed by Dr. Egan.

Click here to download Dr. Egan's complete "Office Policies and Practices" information

Patient Registration Form

Patient Name

First Name

Last Name

Patient's Date of Birth

MM

DD

YYYY

Gender

Male

Female

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

(###)

###

####

Communication

Please indicate if Dr. Egan may leave voice messages on the above phone number. By checking the 'yes' box below, you are agreeing to allow Dr. Egan to leave voice messages relating to the patient's mental health care at that phone number.

Yes

No

School

if enrolled

Is the patient currently seeing a psychiatrist

yes

no

Current Psychiatrist

If patient is currently seeing another psychiatrist please list name and phone number

Is the Patient currently seeing a therapist

yes

no

Current Therapist

If the patient is currently seeing a therapist please list name and phone number

Primary Care Physician

Please list the primary care physician and phone number

Please list all current medications including vitamins and supplements:

Include Medication Name, Dose (e.g. 2mg) and Frequency (e.g. twice a day)

Parent/Guardian #1 Information

Adult Patients can scroll to the bottom and submit form. No more information is needed.

Parent/Guardian #1 Name

only fill out if patient is a minor

First Name

Last Name

Relationship to Patient

Parent Address if different from Patient

leave blank if same as patient

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent #1 Home phone

only fill out if patient is a minor

(###)

###

####

Cell Phone

only fill out if patient is a minor

(###)

###

####

Work Phone

only fill out if patient is a minor

(###)

###

####

Email Address

only fill out if patient is a minor

Parent #1 Birthdate

only fill out if patient is a minor

MM

DD

YYYY

Parent #1 Employer

only fill out if patient is a minor

Parent #1 Occupation

only fill out if patient is a minor

Parent/Guardian #2 information

only fill out if patient is a minor

Parent/Guardian #2 Name

only fill out if patient is a minor

First Name

Last Name

Relationship to Patient

only fill out if patient is a minor

Address

leave blank if same as above

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian #2 Home Phone

only fill out if patient is a minor

(###)

###

####

Parent/Guardian #2 Cell Phone

only fill out if patient is a minor

(###)

###

####

Parent/Guardian #2 Work Phone

only fill out if patient is a minor

(###)

###

####

Parent/Guardian #2 email

only fill out if patient is a minor

Parent/Guardian #2 Birthdate

only fill out if patient is a minor

MM

DD

YYYY

Parent/Guardian #2 Employer

only fill out if patient is a minor

Parent/Guardian #2 Occupation

only fill out if patient is a minor

New Patient Consent To Treatment Form

Name of Patient

First Name

Last Name

Name of Parent or Guardian completing this form if Patient is a minor

First Name

Last Name

Please check "I Agree" next to each statement indicating your agreement with the statement. Please only select "I agree" for the statements you agree with.

“My decision to seek services from Linslee Egan, M.D. is voluntary. I have read the document entitled, “Office Policies and Practices,” and I understand the policies and procedures detailed in it. I agree to adhere to the policies and procedures detailed in this document and I consent receive services from Linslee Egan, M.D.”

I agree

I do not agree

“I understand that psychotherapy involves both risks and benefits. Risks include experiencing painful anxiety, emotions, cognitions, memories, and impulses. Although there is an expectation that psychotherapy will be beneficial, there is no guarantee of benefit. Possible benefits include lower anxiety, less behavioral impairment, clearer cognitions, and improved emotional closeness with others. I understand these risks and benefits and I consent to psychotherapy from Linslee Egan, M.D.”

I agree

I do not agree

“I understand that Dr. Egan regularly receives professional consultation with regard to patient care. I consent to have Dr. Egan disclose my private information to consultants and colleagues for the purpose of professional consultation.”

I agree

I do not agree

Please E-Sign below to indicate that you agree with all statements above and that you consent to receive services from Linslee Egan, M.D.

Today's Date

MM

DD

YYYY

E-check Consent

PAYMENT AUTHORIZATION FORM I authorize Linslee Egan, M.D. to initiate either an electronic debit or to create and process a demand draft against my bank account on or after May 18, 2016 for psychiatry services. I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law. My account information is as follows:

Parent/Guardian if patient is a minor

Bank ABA Number (Routing Number printed on your check)

Please email a photo of a voided check for account verification to office@eganmd.net

Bank Account Number

Bank Account Type

(Checking/Savings/Business Checking)

Name of Bank

Phone Number associated with account

(###)

###

####

Your Email Address

Where you'd like automated superbills sent.

E-Signature (patient or parent/guardian)

By typing your name you consent to electronic debit for psychiatry services.

First Name

Last Name

Patient Billing Form

Thank you for choosing to receive your or your child’s psychiatric and/or psychotherapeutic care from Linslee Egan, M.D. I am not in-network for any insurance companies and I require patients and/or identified responsible parties to pay up front for all services.

Although you may receive reimbursement from your insurance company for some or all of the cost of care, you must identify who will provide payment at the time of service. Most of my patients prefer automatic e-check payments which is the easiest way to pay for sessions for my patients as well as myself but I also accept cash, or check and I keep a credit card on file as a backup.

If you choose to not utilize the auto pay, please bring the cash or check(s) to each appointment. Please complete the attached credit card authorization form for at least one credit card, which will be keep on file as a back-up to ensure payment for services.

Who will be responsible for paying for services provided to you or your child by Linslee Egan, M.D.?

First Name

Last Name

Although I do not accept insurance, many insurance companies will reimburse you for some of the cost of your care. The amount your insurance company will reimburse you depends on many factors, including the following:

1. Your insurance plan: Most HMO plans do not provide any out-of-network benefits and will not reimburse you for my services. PPO plans are more likely to provide an out-of-network benefit and to reimburse you for some of the cost of your care.

2. The patient’s diagnoses, if any: Insurance companies provide more mental health coverage for certain diagnoses, called “parity” diagnoses.

3. The number of mental health services received: Many insurance plans will only reimburse for a certain number of mental health services (particularly psychotherapy visits) per year. Once that number is exceeded, they will not reimburse for any additional visits.

4. The type of service provided: For billing and insurance purposes, each health care visit is given one or more “procedure codes” that describe the services provided during the visit. For example, a psychotherapy appointment that lasts for 45 minutes and does not involve any medication management will generally be given the code 90806. The charge for each visit depends on the type of services provided during the visit, as described by the visit’s procedure code(s). Likewise, the amount of money your insurance company reimburses you for a visit will depend on the visit’s procedure code(s).

5. Submission of a reimbursement request form: You must submit a request to your insurance company asking for reimbursement. Each insurance company’s process for requesting reimbursement is slightly different. If you would like your insurance company to reimburse you, you should visit your insurance company’s website or contact them to learn how to request reimbursement. Most insurance companies have a form you can download from their website, complete, and submit to them to request reimbursement. When you submit your reimbursement request, you must include proof that you received services. I can provide you that proof in the form of a specialized health care services receipt, called a Superbill. If you would like to submit a request for reimbursement to your insurance company for a service provided to you by Linslee Egan, M.D., please ask me to give you a Superbill for that service.

Who will be responsible for paying for services?

First Name

Last Name

Most of my patients prefer to pay for their sessions with electronic check withdraws. It's the easiest for both myself and my patients. I keep a credit card on file as a backup to ensure payment for services. If payment is not received at the time of service or if no prior plan is in place, I may use this credit card as a payment method to pay your balance.

Visa

Matercard

American Express

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Credit Card Number

Expiration Date

cvv code

I hereby authorize Linslee Egan, M.D. To charge my credit card for any unpaid fees for:

Type name here to E-Sign

Electronic Communication Consent Form

This form outlines the guidelines for electronic communication and documents your consent to use electronic communication with you or your child’s doctor. IN A MEDICAL EMERGENCY, DO NOT USE ELECTRONIC COMMUNICATION. DIAL 911 OR PROCEED TO THE NEAREST EMERGENCY DEPARTMENT.

Email: Email is not a private form of communication, but is more like a postcard that can be viewed by anyone with access to certain areas of the internet. Email should not be used for urgent or emergent matters, as your doctor may not check email frequently enough to respond in a timely manner. Email may be used to address routine issues only (e.g. appointment times, routine follow-up inquiries, questions about prescriptions, medication refills, referrals, billing questions). If email is used, please note the following:

1) All clinically relevant emails regarding care with Linslee Egan, M.D. will be included in the patient’s medical record.

2) If you have not received a response within 48 hours to an email you sent to your doctor, please phone your doctor directly to follow-up.

3) Either you or your doctor may request via email or letter to discontinue using email as a means of communication.

Text Messaging: Your doctor may use a work cell phone that receives and sends text messages. Text messaging is to be used for routine issues only (e.g. appointment times, routine follow-up inquiries, questions about prescriptions, medication refills, referrals, billing questions). Text messaging should not be used for urgent or emergent matters, as your doctor may not check texts frequently enough to respond in a timely manner. If text messaging is used, please note the following:

1) All clinically relevant text message content regarding care with Linslee Egan, M.D. will be included in the patient’s medical record.

2) If you have not received a response within 24 hours to a text message you sent to your doctor, please phone your doctor directly to follow-up.

3) Either you or your doctor may request in writing to discontinue using text messaging as a means of communication.

DISCLAIMER: Linslee Egan, M.D. is not responsible for electronic communications that are lost due to technical failures. Although I have implemented reasonable technical safeguards, I cannot and do not guarantee the privacy, security, or confidentiality of electronic communications. Due to the nature of electronic communications, there is a potential that emails and/or text messages may be intercepted, altered, forwarded, or read by others. You should not communicate electronically with your doctor if any of the foregoing presents a concern to you.

I acknowledge that I have read and fully understand this consent form and that I voluntarily request the use of electronic communications with Linslee Egan, M.D.

E-SIGN this Document stating your understanding of Dr. Egan's policies on communications.

Today's Date

MM

DD

YYYY

6- Office Policies 2018

Patient Name

First Name

Last Name

Parent/Guardian if Patient is a minor

First Name

Last Name

1. Scheduling and Billing

As many of you already know, my assistant Teresa aids in scheduling and billing. For the quickest response, please direct all questions pertaining to these matters directly to her at office@eganmd.net - All medical and psychiatric questions should continue to be sent directly to me.

I understand

2. Email Response and Text

Although I do read emails regularly, I’m not always able to respond right away. If it is an urgent matter please email me with URGENT in the subject line and I will respond as quickly as I can however email response times for less urgent issues could be close to 48 hours. If it is urgent that you speak to me immediately, you may also text me at my office number in addition to emailing as well as calling.

I understand

3. Superbills

Receipts are now automatically generated from our billing platform after each e-check charge is processed. These receipts can be submitted to insurance for reimbursement. If you participate in the e-check autopayment and do no receive automatic receipts please contact us at office@eganmd.net to verify we have the correct email address on file. If you do not participate in the auto pay, you’ll still need to contact us to request a superbill. If you participate in the e-check program and would NOT like to receive automated superbills please send an email to office@eganmd.net requesting your removal.

I Understand

4. Cancellation

If a patient needs to cancel a previously scheduled appointment, I ask that he or she inform our office of this as soon as possible. If I am informed of the cancellation more than 1 BUSINESS day before the appointment, no fees will be charged for the cancellation. If I am informed of the cancellation less than 1 business day before the appointment, the patient or responsible parties will be charged 50% of the fee that would have applied to the scheduled appointment. After 2 cancellations with less than 1 business day of notice, 100% of the appointment fee will be charged from then on. If an appointment is cancelled 4 hours or less before the scheduled time it will also be charged the full appointment fee.

I understand

5. Missed Appointments

Missed appointments with no notification given to Dr. Egan will be billed at 100% of the appointment fee.

I understand

6. Automated Scheduling Confirmation

Dr. Egan utilizes automated appointment reminders for all scheduled appointments. If you do not receive these and would like to, please contact Teresa at office@eganmd.net — If you think you have an appointment and do not receive an email confirmation, please email Dr. Egan’s office to confirm the appointment. Our system generates email reminders as a courtesy, but it is the responsibility of the patients to remember the appointments made in person, over email, text, or phone and if they are not receiving reminders to let us know directly so we can rectify the situation. Appointments made are considered confirmed unless we are notified otherwise.

I understand

7. Medication Refills

For medication refill requests, please allow 3-5 days for completion.

I understand

By checking the above boxes you acknowledge your understanding of Dr. Egan’s Policies and that you have been given her full office policy pdf located above.