Forms

New Patient Form (NPF)

OhanaPsych, LLC 12034 Big Canoe, Jasper, GA 30143 Office: 808-777-9460 Fax: 808-217-9174

In order to provide you with the best psychiatric care and treatment possible, please fill out all fields. Questions with an asterisk (*) are required. At the end of the form, click the submit button to securely send us your form. Mahalo.

Today's date: *

Patient's first name: *

Middle initial:

Patient's last name: *

Patient's birthdate: *

Mailing address, city, state, zip code: *

Physical street address, city, state, zip code: *

This is required by pharmacies.

Do you have an email address?* Yes No

Please skip next box if no.

Email address:

Cell phone number: *

Home phone number:

New Patient Registration Form

Picture of ID front: *

Image size must be less than 10MB.

Picture of primary insurance card front: *

Image size must be less than 10MB.

Picture of primary insurance card back: *

Image size must be less than 10MB.

Picture of secondary insurance card front:

Image size must be less than 10MB.

Picture of secondary insurance card back: *

Image size must be less than 10MB.

Picture of secondary insurance card back: *

Image size must be less than 10MB.

Preferred language:

This practice is a safe and inclusive practice for LGBTQIA+.

Sex on birth certificate:* Male Female

(Required for billing)

Gender identity: Male Female Transgender male/trans man/female to male Transgender female/trans-woman/male to female Gender queer, neither exclusively male nor female Additional gender category or other (please specify) Patient declines to specify

What are your pronouns?

Emergency Contact full name: *

Emergency Contact relationship: *

Emergency Contact phone number: *

Do you have a pharmacy?* Yes No

List pharmacy name, street address, and phone number. *

This is required so we can send your prescription. If none list NONE.

Do you have a Legal Guardian? *

Yes No

If patient is not a minor, or have a legal guardian skip down to the insurance section.

If patient is a minor, or has a legal guardian, please complete the following:

Parent or Legal Guardian full name:

Parent or Legal Guardian birthdate:

Parent or Legal Guardian photo ID:

Please upload a picture of your driver's license or passport. Image size must be less than 10MB.

Parent or Legal Guardian phone number and address:

Relationship to patient:

We need a copy of the complete document showing you have legal guardianship. If it does not fit in the 4 photo boxes below, please call our office for an alternative way to send the document.

Guardianship document page 1:

Please upload photo. Image size must be less than 10MB.

Guardianship document page 2:

Please upload photo. Image size must be less than 10MB.

Guardianship document page 3:

Please upload photo. Image size must be less than 10MB.

Guardianship document page 4:

Please upload photo. Image size must be less than 10MB.

Insurance Policy Information

Your primary insurance is: *

Your Policy ID# *

Your Group ID#

What is the full name of the policy holder? *

Policy holder's sex:* Male Female

Policy holder's birthdate: *

Policy holder's address: *

Policy holder's SSN:

What is your relationship to the policy holder?* I am the policy holder I am a dependent I am the spouse Other

Secondary Insurance Information

Your secondary insurance is:

Your Policy ID#

Your Group ID#

What is the full name of the policy holder?

Policy holder's sex: Male Female

Policy holder's birthdate:

Policy holder's address:

Policy holder's SSN:

What is your relationship to the policy holder? I am the policy holder I am a dependent I am the spouse Other

The following information includes our Notice of HIPAA Privacy Practices, Office Policies and Services, Financial Policies, Information about Telepsychiatry Services, and Consent for Treatment.

Legal Definition of Physician may be used interchangeably with Provider, Counselor, Therapist, APRN, Nurse Practitioner.

Notice of HIPAA Privacy Practices

HIPAA is the "Health Insurance Portability and Accountability Act", a Federal law that provides privacy protections and patient rights with regard to the use and disclosure of your "Protected Health Information"(PHI) used for the purpose of treatment, payment, and health care operations. “Protected Health Information” (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. This Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this notice please ask us. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all PHI that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may call the office and request that a revised copy be sent to you, or you may ask for one at the time of your appointment. You may revoke this agreement in writing at any time.

ABUSE OR NEGLECT: We may disclose your Protected Health Information (PHI) to a public health authority that is authorized by law to receive reports of child abuse or neglect, or elder abuse. In addition, we may disclose your PHI if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

COMMUNICATION BARRIER: We may use and disclose your Protected Health Information (PHI) if your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.

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 by sending a written note to us detailing your complaint. We will not retaliate against you for filing a complaint.

CRIMINAL ACTIVITY: Consistent with applicable federal and state laws, we may disclose your Protected Health Information (PHI) if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

EMERGENCIES: We may use or disclose your Protected Health Information (PHI) in an emergency treatment situation. If this happens, your physician will try to obtain your consent as soon as reasonably practical after the delivery of treatment. If your physician or another physician in the practice is required by law to treat you and the physician has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your PHI to treat you.

FOOD AND DRUG ADMINISTRATION (FDA): We may disclose your protected health information to a person or company required by the FDA to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

HEALTHCARE OPERATIONS: We may use or disclose, as-needed, your Protected Health Information (PHI) in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities. For example, we may disclose your PHI to medical school students that see patients at our office. We may use or disclose your PHI to contact you to remind you of your appointment. We will share your PHI with third party “business associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your PHI we will have a written contract that contains terms that will protect the privacy of your PHI. We may use or disclose your PHI to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your PHI for other marketing activities. For example, your name and address may be used to send you information about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact us by sending a written note at above address to request that these materials not be sent to you. Uses and Disclosures of PHI Based upon Your Written Authorization: Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization. Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object: We may use and disclose your PHI in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your PHI. If you are not present or able to agree or object to the use or disclosure of the PHI then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is relevant to your health care will be disclosed.

LAW ENFORCEMENT: We may also disclose Protected Health Information (PHI) so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of the practice, and (6) medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred. Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. PHI may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

LEGAL PROCEEDINGS: We may disclose Protected Health Information (PHI) in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

OTHERS INVOLVED IN YOUR HEALTHCARE: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information (PHI) that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your PHI to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or others involved in your healthcare.

PAYMENT: Your Protected Health Information (PHI) will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant PHI be disclosed to the health plan to obtain approval for the hospital admission.

PUBLIC HEALTH: We may disclose your Protected Health Information (PHI) for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your PHI if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority. Communicable Diseases: We may disclose your PHI if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Health Oversight: We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

REQUIRED BY LAW: We may use or disclose your Protected Health Information (PHI) to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

REQUIRED USES AND DISCLOSURES: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq.

RESEARCH: We may disclose your Protected Health Information (PHI) to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.

TREATMENT: We will use and disclose your Protected Health Information (PHI) to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your PHI. For example, we would disclose your PHI as necessary, to a home health agency that provides care to you. We will also disclose PHI to other physicians who may be treating you when we have the necessary permission from you to disclose your PHI. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your PHI to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your diagnosis or treatment to your physician.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION (PHI): You will be asked by us to sign a consent form. Once you have consented to use and disclosure of your PHI for treatment, payment and health care operations by signing the consent form, we will use or disclose your PHI as described in this section. Your PHI may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your PHI may also be used and disclosed to pay your health care bills and to support the operation of the physician’s practice. Following are examples of the types of uses and disclosures of your PHI that our office is permitted to make once you have signed our consent form.

WORKER'S COMPENSATION: Your Protected Health Information (PHI) may be disclosed by us as authorized to comply with worker's compensation laws and similar legally-established programs.

YOUR RIGHTS: Following is a statement of your rights with respect to your Protected Health Information (PHI) and a brief description of how you may exercise these rights. You have the right to inspect and copy your PHI. This means you may inspect and obtain a copy of PHI about you that is contained in a designated record set for as long as we maintain the PHI. A “designated record set” contains medical and billing records and any other records that your physician and the practice use for making decisions about you. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact us by sending a written request if you have questions about access to your medical record. You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by supplying us with a signed statement specifying your requests. This document will be placed in your permanent file. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing by mail. You may have the right to have your physician amend your PHI. This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact us by sending a written request if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. You have the right to obtain a paper copy of this notice from us even if you have agreed to accept this notice electronically.

Office Policies and Services

CANCELLATION, NO-SHOW & LATE ARRIVAL POLICY: Once an appointment is scheduled, you will be expected to attend it, unless you cancel it with at least 24-hours notice. A missed appointment fee ($50) will be charged for an appointment not cancelled at least 24-hours before start of the appointment time or for a no-show. Insurance companies do not reimburse us for a no-show or a late cancellation. After 2 no-shows or late cancellations for an evaluation, we will not schedule a third time. After 3 no-shows or late cancellations you may be discharged from the practice. Please arrive on time for your appointment. Patients arriving more than 10 minutes late may be asked to reschedule. A missed appointment fee ($50) will be charged. Exception: If you have Quest insurance we are not allowed to charge you a fee for a no-show or late cancellation.

CONFIDENTIALITY: Your privacy is important to us. All protected health information (PHI) will be kept confidential. In most cases we will obtain your consent prior to releasing any PHI; however, records and/or PHI may be released regardless of consent in the following circumstances: According to state and local laws, we must report to the appropriate agencies all cases of physical and sexual abuse or neglect of minors (children under the age of 18), the disabled, and the elderly. According to state and local laws, we must report to the appropriate agencies all cases in which there exists a danger to self and/or others. When authorized by the recipient of services, in order to process medical insurance claims and authorized payment of benefits. In the event that a patient is in need of emergency services and other medical personnel need to be contacted. If you become involved in specific kinds of legal proceedings, the courts may subpoena information concerning your treatment.

EMAIL, TEXT, CELL PHONE AND FAX COMMUNICATION: It is very important to be aware that email and cell phone (also cordless phone) communication can be relatively easily accessed by unauthorized people and, hence, the privacy and confidentiality of such communication can be easily compromised. Please notify your treatment provider at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices. Please do not use email or faxes in emergency situations. Please do not send PHI through unsecure email or text. Instead use secure text, secure email or fax. If you need to discuss clinical matters in between sessions, please use the phone (a landline is the most confidential means of communication). I acknowledge that OhanaPsych, LLC may communicate with me by phone, voicemail, text, email or fax for the purpose of appointment scheduling, reminders, and cancellations. OhanaPsych, LLC will use secure text or secure email to communicate any health related information.

EMERGENCY AND AFTER-HOURS SERVICES: If you need emergency services, call 911 or proceed to the nearest hospital emergency room. For the Hawaii Crisis Line on Oahu call 808-832-3100, on the Outer Islands call 800-753-6879.

MEDICATION REFILL POLICY: It is your responsibility to fill out a Refill Request Form before you run out of medications. We have 72 hours to respond to your request. Patients on controlled medications need to be seen within 30 days. Only in rare circumstances can this be extended to more than 30 days. There is a $10.00 per prescription fee to rewrite any expired prescriptions. We require that patients on psychiatric medication be seen at least once every 30-90 days. If a patient has not been seen in by the provider in the last 90 days, we will not issue a refill without a scheduled follow-up appointment. We also have your permission to interrogate your pharmacy electronically. This allows us to have the ability for medication reconciliations at every visit. Prescriptions will ONLY be sent to pharmacies in the state of Hawaii.

OFFICE HOURS: The office is open Monday-Friday from 7am-5pm by appointment. When we close the office for holidays or vacations this will be stated on the voicemail greeting.

PATIENT RIGHTS: HIPAA provides you with rights with regard to your clinical record and disclosures of PHI. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records, and the right to request a paper copy of this agreement.

PROFESSIONAL RECORDS: The laws and standards of our profession require that we keep protected health information (PHI) about you in medical record. Except in unusual circumstances that involve danger to yourself and/or others, you may examine and/or receive a copy of your clinical record if you request it in writing. Because these are professional records, they can be confusing if read without the guidance of a mental health professional. For this reason, we recommend that you initially review them in our presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, we are allowed to charge a copying fee of $25.00 or more. If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon your request. Insurance companies can request and receive a copy of your clinical record.

PSYCHIATRIC SERVICES: We offer the following telehealth psychiatric services: Initial diagnostic evaluation, medication management services, and brief psychotherapy services.

TREATMENT OF MINORS: Treatment of patients under the age of 18 will be provided only with the consent of the parent or legal guardian. In cases of divorce, a copy of the custody agreement must be provided. Most custody decrees entitle the non-custodial parent to access the health record without consent from the custodial parent. Patients under 18 years of age (who are not emancipated) and their parents should be aware that the law may allow parents to examine their child’s treatment records. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections they may have. If the patient is a minor, they will not be seen without their legal guardian present.

Financial Policies

BILLING AND PAYMENT POLICY: Payment (i.e. cash pay, copays, payment towards deductible) is due prior to your appointment on the day services are rendered. Our failure to collect these amounts may be a violation of our contract with your insurance company. In addition, your failure to pay the required co-amounts is a violation of your financial responsibility for coverage. If we are an in-network provider for your insurance, we will collect the portion of the fee that the insurance does not cover. Unless proof from the insurance company is provided at the time of the appointment stating that your deductible has been met, all deductibles will be due at the time of service. If the insurance company also pays for the office visit, we will gladly reimburse you. If your account is not paid in a timely manner and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency, hiring an attorney, or utilizing other options, which will require us to disclose otherwise confidential information. In most collection situations, the information released includes the patient’s name, contact information, the nature of services provided and the amount due. If such legal action is necessary, these costs will be included in the claim. We are required by law to obtain your signature for permission to release information to your insurance carrier. Please assist us in complying with your insurance requirements. We expect payment of all your services rendered within 60 days. It may become necessary for you to pay your account in full if your insurance company fails to pay for services within 60 days. It is your responsibility to understand your coverage and benefits, including pre-certification, referral and authorization requirements. We will, however assist you to ensure that all plan requirements are met. I understand that OhanaPsych, LLC will file and attempt to collect from my insurance company. I agree to waive any insurance company rights that would prevent me from being responsible for unpaid charges. If there is a change in your insurance coverage, your address, or other demographic information, please let us know before your visit.

FORMS AND LETTERS: Any additional paperwork, letters, or forms not specifically related to intra-office care, will be subject to a fee based on the time it takes to complete the documentation at a rate of $35 per each 15 minutes. If you are requesting an electronic copy of your chart, the fee is $25. Paper copies will be charged at a rate of .25 per page plus postage. Fees will need to be paid prior to release of records.

INSURANCE REIMBURSEMENT: If you have a health insurance policy, we can fill out forms and provide you with assistance in helping you receive your benefits. Please note that you, not your insurance company, are responsible for full payment of our fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, we recommend that you call your plan administrator. Your contract with your health insurance company requires that we provide the health insurance company information relevant to the services that we provide to you. We are required to provide a clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, we will make every effort to release the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files. In some cases, the insurance companies may share clinical information with a national medical information databank. We can provide you with a copy of any report we submit, at your request. By signing this Agreement, you agree that I can provide requested information to your insurance carrier.

TELEPHONE CONTACT FEES: Providers may charge you a fee for telephone calls in between scheduled appointments that relate to your care. We may charge a minimum of $25 for telephone calls, with total charges based on the amount of time spent. This does not apply to calls with the office staff to discuss scheduling, billing, and questions.

Informed Consent for Telepsychiatry Services

Telepsychiatry is the delivery of psychiatric (or psychotherapeutic) services using interactive audio and visual (video) electronic systems where the provider and the patient are not in the same physical location. The interactive electronic systems include network and software security protocols to protect patient information and safeguard the data exchanged. REQUIREMENTS: 1. A computer, tablet or phone with a camera and microphone to video conference using a HIPAA compliant online company specializing in telemedicine. 2. Patient is required to be physically present within the state of Hawaii at the time of service. POTENTIAL BENEFITS: Telepsychiatry provides convenience and increased accessibility to psychiatric care for individuals who are unable to be treated face-to-face due to temporary circumstances such as being away at college, having a physical limitation preventing travel to an office, or a public health emergency. POTENTIAL RISKS: As with any medical procedure, there may be potential risks associated with the use of a telepsychiatry. These risks include, but may not be limited to: 1. Therapy conducted online is technical in nature and problems may occasionally occur with internet connectivity. Difficulties with hardware, software, equipment, and/or services supplied by a third party may result in service interruptions. Any problems with internet availability or connectivity are outside the control of the provider and the provider makes no guarantee that such services will be available or work as expected. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video conferencing, the provider will call the patient back at the phone number provided on this form. 2. Information transmitted may not be sufficient ( for example; poor resolution of video) to allow for appropriate medical decision making by the psychiatrist or therapist. 3. The provider may not be able to provide treatment to the patient using interactive electronics equipment not provide for or arranged for emergency care that the patient may require in case of connection failure. 4. Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment. 5. Although highly unlikely, security protocols can fail, causing a breach of privacy of confidential medical information. 6. A lack of access to all the information that might be available in a face-to-face visit but not in a telepsychiatry session may result in errors in medical judgment.

MY RIGHTS, RESPONSIBILITIES AND EXPECTATIONS WITH TELEPSYCHIATRY: MY RIGHTS: 1. I understand that the laws that protect my privacy and confidentiality of medical information also apply to telepsychiatry. 2. I understand that the technology used by the provider is encrypted to prevent unauthorized access to my private medical information. 3. I have the right to withhold or withdraw my consent to the use of telepsychiatry during the course of my care at any time. 4. I understand that my withdrawal of consent will not affect any future care or treatment. I understand that the provider has a right to withhold or withdraw his or her consent for the use of telepsychiatry during the course of my care at any time. 5. I understand that all the rules that apply to the practice of medicine in the state of Hawaii also apply to telepsychiatry. 6. I understand that the provider would not record any of our telepsychiatry session without my written consent. 7. I understand that the provider will not allow any other individual to listen to, review or record my telepsychiatry session without my expressed written permission. MY RESPONSIBILITIES: 1. I agree to take full responsibility for the security of any communication or treatment information involved with my own device and with my own physical location 2. I understand that I am solely responsible for maintaining the strict confidentiality of my user ID and password, and I would not allow another person to use my ID to access the services. 3. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation. 4. I understand that the company that the provider has chosen to conduct online appointments (see guidelines) is an independent company specializing in HIPAA compliant telemedicine. My provider has no responsibility for that company’s operation or security of my protected health information. In addition, the company might send emails or communications, such as appointment reminders. I understand that the provider is not responsible for this communication. 5. I will not record any telepsychiatry sessions without written consent from the provider. 6. I will inform the provider if any other person can hear or see any part of our session before the session begins. 7. I understand that I, not the provider, am responsible for providing and configuring electronic equipment used on a device which is used for telepsychiatry. 8. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins. 9. I agree to revert to a telephone voice session utilizing the indicated backup telephone number provided below should a video connection not function properly. If I am experiencing any technical difficulties, OhanaPsych, LLC encourages me to call/contact the company chosen for online appointments for technical support. 10. I have read and understand that all of the clinic policies of OhanaPsych, LLC apply to all telemedicine as well as all in person visits. 11. I understand that I agree to be seen face to face at least once every six months to maintain therapeutic services and a provider/patient relationship if possible. 12. I consent to paying fees that are the same as an in-office visit for the type and length of service provided to OhanaPsych, LLC at the time of service. 13. I understand that a telepsychiatry appointment is scheduled the same as an in-office appointment would be, and should I not be available for the appointment or cancel it less than one full business day in advance, there will be a charge for a missed appointment for the time my provider has reserved for the scheduled appointment. 14. I understand that it is my responsibility to check for the availability of telepsychiatry service options with my insurance carrier. 15. I understand that in case of life-threatening emergency situations, my provider can call for emergency services or police/911 for assistance.

I RECEIVED A COPY OF THE HIPAA NOTICE OF PRIVACY PRACTICES.* Yes, I agree. No, I do not agree.

I AGREE TO THE FINANCIAL POLICIES.* Yes, I agree. No, I do not agree.

I AGREE FOR OHANAPSYCH TO CALL, TEXT, OR EMAIL ME TO COLLECT MY COPAY OR OUTSTANDING BALANCE IF I HAVE ONE.* Yes, I agree. No, I do not agree.

I CONSENT TO THE USE OF TELEPSYCHIATRY SERVICES.* Yes, I agree. No, I do not agree.

I AGREE FOR THE RECEPTIONIST TO CALL ME TO TEST MY VIDEO CONNECTION BEFORE MY APPOINTMENT IS SCHEDULED, SO THAT I HAVE A SUCCESSFUL EXPERIENCE WITH TELEHEALTH.* Yes, I agree. No, I do not agree.

Certainly do have the right to not agree to the above conditions, however you will not be a good fit in our practice, and we wish you the best, we will not see you if you do not agree to the conditions.

Patient's first and last name: *

Patient's birthdate: *

Please sign with your legal signature. *

You may revoke this agreement in writing at any time. (Client to sign, Guardian, Parent if minor.) If unable to sign print UNABLE explain below.

I am the:* Patient Parent Legal guardian Other

Only client, parent, or guardian. Can sign this form for client legally. If other please fill out next box. (We will not see clients that are unaware that they are seeing a psychiatric provider).

Other and why not signed by client, parent, or guardian.

Before this client is seen we will need consent forms signed. We can do this before the visit on our tele-psychiatry video/audio platform or at your precheck visit.

Today's date: *

Other source of referral? Please list how you found us:

Do you have a case manager?* Yes No

If no skip the next two boxes

Other Case Management Company not listed above:

Please list the name of your case manager and their phone number:

What brings you in for this visit? Please describe your symptoms so the provider knows why you are seeking treatment. *

Are you taking any medications?* Yes No

Including over the counter, vitamins, supplements, and medical marijuana. Please list your medications in the next box. If you are not on any medication state none.

Please list all medications you are currently taking with dosages and frequency. If none state none: *

Including over the counter, vitamins, supplements and medical marijuana.

Any medication allergies?* Yes No

If no skip the next box

Please list medication allergies, severity of allergy, and physical reactions:

The rest of this form is not required, however it will make your initial evaluation go faster. If you choose not to complete the rest of the form, please go to the end of the form and click the submit button to transmit the form securely to our office. Mahalo.

Medical History

Who is your Primary Care Provider?

(PCP or PCM)

Primary Care Provider phone number:

Do you have a counselor or therapist? Yes No

If no skip the next box

Please list their name and frequency seen:

Do you have (or did have) a psychiatric provider? Yes No

If no skip the next 2 boxes

Your psychiatric provider's name:

Last date you were seen by your psychiatric provider?

Previous psychiatric diagnosis? Yes No Unknown

If no or unknown skip the next question

Psychiatric diagnosis given?

Previous suicidal behavior or self harm behavior? Yes No

If no skip the next box

Suicidal / self harm behavior dates, method used:

Previous psychiatric hospitalization? Yes No

If no skip the next question

Psychiatric hospital name, dates, and reason for hospitalization:

Please list all

Have you taken any previous psychiatric medications? Yes No

If no skip the next 3 boxes

Please list all previous psychiatric medications by name:

Did you have side effects from these medications?

List of psychiatric medication you would rather never use again:

Have you ever had a seizure? Yes No

Type of seizure? Date of last seizure?

Did you have any developmental delays in childhood? Yes No Unknown

If no or unknown skip next question

Delays were:

Difficulty in walking Difficulty in talking Difficulty in grade school Special education Other developmental delay

Mark all that apply

Before you were born and still in utero any exposure to substances? Yes No Unknown

Such as alcohol, prescription drugs, street drugs, or tobacco. If no known exposure skip next box.

Please list substances possibly exposed to in utero:

Substances possibly exposed to in your mom's belly, before you were born

History of any surgery? Yes No

If no skip next two questions

Other surgery not listed:

Social History

Highest level of education:

Do you have any children? Yes No

If no skip next question.

What is your current occupation?

Have you applied for disability or are you planning to apply for disability? Yes No

Religious affiliations? Yes No

If no skip next box

Religious affiliations or beliefs? Please explain.

History of trauma therapy? Yes No

Legal History

History of violent crime? Yes No

If no please skip next box

Describe violent crime:

History of a DUI? Yes No

If no please skip next box

DUI substance used? Dates of DUI? Treatment recommendations?

Substance Use History

Do you use any tobacco products? Yes No

If no skip the next 4 questions

Amount of cigarettes smoked daily?

Have you ever tried to stop smoking? Yes No

Are you interested in any smoking cessation products? Yes No

Have you ever been treated for substance abuse? Yes No

If no skip the next 3 boxes.

Substance treated for?

Facility treated at for substance use? (please list all)

Did you complete treatment? Yes No Was kicked out Left before program was done

First substance ever used was? My age of use was?

List all substances used in the past 1 year:

Do you feel that there is a substance that you need to cut back on? Yes No

If no skip next box

Substance?

Do you experience any cravings for substances? Yes No

If no skip next box

Substance?

Family Health History

Does anyone in your biological family (living or deceased) have any of the following: Hypertension, hyperlipidemia, cancer, stroke, heart disease, diabetes, hypo or hyperthyroidism?

High Blood Pressure High Cholesterol Cancer Stroke Heart Disease Diabetes Hypothyroidism Unknown Adopted

May choose more than one.

Family history of mental illness? Yes No Unknown

If no or unknown skip the next question.

Type of mental illness?

Family history of suicide? Yes No Unknown

Family member(s) that committed suicide?

Please hit the Submit button to return this form. After we review your form, our staff will call you to schedule. Mahalo.

Revised last (8/26/2024)

New Patient Form (NPF) will be submitted to OhanaPsych

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