New Patient Information Form

Patient Information

Name *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Date of Birth *

Age *

Gender *

Male

Female

Marital Status *

Best phone number to reach you *

OK to leave a message at this number?

Yes

Email address *

Please list all current medications

Please list all medications which you are allergic to

Name of person who referred you

If patient is a minor:

Guardian name

Guardian phone number

Emergency Contact

Emergency contact name *

Emergency contact phone *

Insurance Information

Maui Mind Care has no managed care contracts, and is not affiliated with any HMO or PPO. Consequently, if you have health insurance and wish to use it to help defray the cost of treatment, you may need to contact your insurance carrier to inquire about out of network benefits. Kindly know that Maui Mind Care does NOT participate in the Medicare Program. If you are a patient who has Medicare coverage but wish to consent to treatment in this office, please sign and date below.

Enter your name as your digital signature in acknowledgement of above information *

Termination Policy

Patients are under no obligation to continue treatment should they decide to terminate at any time. However, if you wish to terminate treatment prematurely, you are strongly encouraged to discuss your thoughts openly.

Payment Policy

All payment is due at the time service is rendered. If you plan on filing with an insurance carrier for payment reimbursement, you may use your office receipt. Maui Mind Care does not routinely mail billing statements for outstanding balances patients may have, unless prior arrangements have been made. All charges 90 days past due are automatically sent to a collection agency. Please be mindful of your balance.

Appointment Changes/Cancellations

Patients are charged full session fees for missed appointments or cancellations made, unless a 24 hour notice is given. Please know that most insurance carriers will not reimburse for missed appointments.

Office Hours

Office hours are by appointment only, Monday through Friday, 9:00AM through 5:00PM.

Emergencies and Phone Policy

Should you wish to contact us between office visits, you are encouraged to call during business hours. You may leave a message on voicemail, and all calls will be returned within 24 business hours. Should you experience a life threatening emergency, you are encouraged to call 911 for assistance. You are then encouraged to notify us. Every effort will be made to return your call promptly. Non-emergent calls made after business hours will be returned as quickly as possible. Kindly know, however, such calls may carry a charge.

Consent to Treatment and Guarantor Responsibility

I have read the policies listed, and I understand and agree with them. I hereby agree to be treated by Maui Mind Care, and when necessary, other physicians covering in their absence. I authorize Maui Mind Care to provide information concerning my treatment to any physician or therapist who referred me to this practice. I agree that I am responsible for all charges for services rendered.

Enter your name as your digital signature in acknowledgement of above information *