PATIENT DEMOGRAPHIC INFORMATION FORM

1 Office of Donald A. Smith, MD. 51 Locust Street, Unit #4. Northampton, MA 01060. Ph(413) 341-5081 Fax(413)-341-5082 Donald A. Smith, MD 2013 If you did not complete these forms in advance and bring them with your initial appointment today, then please complete them, and sign them now. Our office does not receive email from patients. We do use a PATIENT portal system to send forms to be completed, and to send appointment reminders. If you have any reports for the Dr. Smith, we would appreciate them in advance. If you cannot get them to us by mail or fax in advance, please bring them with you to your appointment. PATIENT DEMOGRAPHIC INFORMATION FORM Today s Date_____ PATIENT INFORMATION : PATIENT s Name _____ Address _____ City_____State_____ Zip_____ Home Phone#_____Mobile/Cel.#_____Work#_____ **Please indicate preferable phone to use Age_____Date of Birth _____ Social Sec.

2 # _____ Married _____Single _____Divorced_____ Other _____ Spouse s Name _____Mobile#_____Work#_____ Employer _____ Occupation _____ Address _____ City _____State _____ Zip_____ Pharmacy Name/City/Phone#_____Phone#_____ REFERRAL INFORMATION : Referred By _____Phone # _____ PRIMARY CARE PERSON AND OTHER PHYSICIANS: Family Physician_____Phone#_____ OB/GYN_____ Phone#_____ Cardiologist_____Phone#_____ Neurologist_____Phone#_____ Rheumatologist_____Phone#_____ Liver Doctor_____Phone#_____ Kidney Doctor_____Phone#_____ Other Specialist _____Phone#_____ EMERGENCY CONTACT INFORMATION : Name_____Relationship_____ Address_____ Cellular Phone# _____Home Phone#_____Work Phone# _____ Who is responsible for payment, if other than self? Name_____Relationship_____ Address_____ Phone_____ Donald A Smith, MD 2013 Office of Donald A.

3 Smith, MD. 51 Locust Street, Unit #4. Northampton, MA 01060. Ph(413) 341-5081 Fax(413)-341-5082 Donald A. Smith, MD 2013 AUTHORIZATION TO DISCLOSE AND OBTAIN MEDICAL INFORMATION FORM Evidence supports including a primary support person or significant other in your treatment plan. Many clinical problems can occur if this permission is revoked. In order for us to better treat you, our office requests that you sign this Release of INFORMATION Form. Please read this form carefully, and discuss any questions that you may have about it with Dr. Smith or our office staff before signing it. We understand you may have specific privacy requests. Please list any specific privacy requests on this form (for example, if you are going through the process of a divorce, you may prefer for us to have no contact with your spouse, and therefore designate a different primary support person.)

4 I understand that by signing this form, I give Dr. Donald A. Smith and his office staff permission to communicate clinical and medical INFORMATION about to the people I list on this form, for the purpose of good continuity of care. I understand that by signing this form, I also give anyone I list on this form permission to communicate clinical and medical INFORMATION about me to Dr. Smith and his office staff. INFORMATION about me that may be communicated, includes: my diagnoses, treatment, laboratory results, drug screening results, urine drug screening results, other clinical INFORMATION ; INFORMATION about my substance abuse, miss-use or suspected diversion of controlled substances; and my HIV/AIDS status. I understand that by law, I am allowed to revoke this permission at any time, and that I will need to do so in writing, by signing the Revoke Permission for Release of INFORMATION Form.

5 I understand and agree that if I chose to revoke permission for future communication with anyone on this form, Dr. Smith and his office staff will only be able to communicate to them that previous permission was revoked, and now he can neither confirm nor deny that I am currently being treated by him. I understand that if I revoke permission for Dr. Smith and his office staff to speak with any people listed on this form, it may result in immediate termination of care with Dr. Smith, based on Dr. Smith s clinical judgment, especially if I revoke permission for communication with people on this form, because I have violated either my Controlled Substance Medication Agreement, and/or my Treatment Contract. Emergency Contact_____Relationship_____ Contact phone numbers_____ Name of Significant Other or Spouse_____Relationship_____ Contact phone Numbers_____ Name of Primary Care Person_____ Office location_____ Contact phone Numbers_____ Individual Therapist s Name_____ Office location_____ Contact phone Numbers_____ Group Therapist s Name_____ Office location _____ Contact phone Numbers_____ Other Medical Provider (Neurologist, Cardiologist, Kidney Specialist, ).

6 Name_____Specialty_____Location_____ Contact phone Numbers_____ Other Person Name_____Relationship_____ Contact phone Numbers_____ My Specific Privacy Requests_____ _____ My signature below means that I have read, understand, and agree to the INFORMATION on this form Signature of Patient_____Date_____ Printed Name of Patient_____Date of Birth_____ Signature of Legal Guardian of Patient_____Date_____ Printed Name of Legal Guardian of Patient_____ Phone Number of Legal Guardian_____ This permission will expire one year from the date of my signature on this form, or on the following date_____ Donald A Smith, MD 2013 Office of Donald A. Smith, MD. 51 Locust Street, Unit #4. Northampton, MA 01060. Ph(413) 341-5081 Fax(413)-341-5082 Donald A. Smith, MD 2013 PAYMENT AND INSURANCE INFORMATION AGREEMENT I fully acknowledge that I am responsible for full payment of the total bill incurred, and that I will need to pay Dr.

7 Smith by check or cash at the beginning of each appointment. I fully acknowledge that I am responsible for filing any forms to my insurance company. I understand that it is my responsibility to know what my insurance company requires, in order for me to be reimbursed, and that I need to let Dr. Smith know this INFORMATION in advance. I understand that if there are delays in payments, or problems with receiving reimbursement from my insurance company, that it is my responsibility to contact my insurance company. By Signing below I acknowledge that I have read and understand the above, and I agree to these terms. _____ Date_____ Signature of person responsible for payment to Dr. Smith for PATIENT named above on this form _____ Printed name of person who signed above signature Donald A Smith, MD 2013 Office of Donald A.

8 Smith, MD. 51 Locust Street, Unit #4. Northampton, MA 01060. Ph(413) 341-5081 Fax(413)-341-5082 Donald A. Smith, MD 2013 RELEASE OF MEDICAL INFORMATION TO YOUR INSURANCE CARRIER FORM for the office of Donald A. Smith, MD Do you have Health Insurance? Yes ____ No____ (If yes, complete the following form) Primary Insurance Co. _____ Policy Holder _____ Relationship_____ Group #_____ ID # (Subscriber #) _____ This signature is to authorize the release of any necessary medical INFORMATION to my insurance carrier. All clinical INFORMATION about me may be released, including my diagnoses, lab results, INFORMATION about substance abuse, HIV/AIDS, and other sexually transmitted diseases. I fully acknowledge that I am responsible for full payment of the total bill incurred. By signing below, I fully acknowledge that I have read this form and agree to the terms as outlined above.

9 _____ Date:_____ PATIENT signature (Or Parent signature , if PATIENT is a minor. Or Guardian signature) _____ Printed name of signature Donald A Smith, MD 2013 Office of Donald A. Smith, MD. 51 Locust Street, Unit #4. Northampton, MA 01060. Ph(413) 341-5081 Fax(413)-341-5082 Donald A. Smith, MD 2013 PRIVACY POLICY FORM for the office of Dr. Donald A. Smith, MD. It is my policy to not to release any INFORMATION regarding your use of my services or your private and confidential INFORMATION . However, with your written permission, my psychiatric services are better provided in collaboration with your therapist and any medical providers you may have. I use an electronic internet-based, medical record system (Valant), fax system (Valant), and prescription program (Valant and Dr. First); I, and those companies (Valant and Dr.)

10 First), am/are all required to keep your INFORMATION protected under the requirements from the Health Care INFORMATION Portability and Accountability Act (HIPPA). The following conditions affect the confidentiality of your INFORMATION : 1.) You may chose to provide written permission for me to release your records or other INFORMATION about you, to anyone you chose to list on either of my two office forms: a.) Authorization Form to Disclose and Obtain Medical INFORMATION b.) Release of Medical INFORMATION to your Insurance Carrier Form You may revoke permission by signing the Revoke Permission for Release of INFORMATION Form , at any time. 2.) If I assess you to be at imminent risk of harming yourself or of harming someone else, then I am legally and ethically obligated to follow certain procedures and disclose INFORMATION about you to try and keep you safe, and to try and keep anyone else who might me in danger safe.