New Patient Forms

As with any medical procedure, there are potential risks associated with the use of telemedicine/telehealth services. These risks include, but may not be limited to:

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine/telehealth services, and that no information obtained in the use of telemedicine/telehealth services which identifies me will disclosed to other entities without my consent.
2. I understand that I have the rights to withhold or withdraw my consent to the use of telemedicine/telehealth during my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded during a telemedicine/telehealth interaction and may receive copies of this information for a reasonable fee.
4. I understand that a variety of alternative methods of medical/health care may be available to me, and that I may choose one or more of these at any time. My doctor/therapist has explained the alternatives to my satisfaction.
5. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
6. I understand that insurance coverage of telehealth sessions may differ based on my insurance plan. It is in my best interest to check with my insurance company regarding the coverage.
7. I understand that I am fully responsible for co-payments and deductible amounts, and that I am fully responsible to pay the provider if telehealth/telemedicine sessions are not covered by my insurance company

I have read and understand the information provided above regarding telehealth/telemedicine services, have discussed it with my physician/therapist, and all of my questions have been answered to my satisfaction. I hereby give consent for the use of telehealth/telemedicine services in my care. I hereby authorize Muhammad Nadeem Shamsi P.C. to use telehealth/telemedicine services in the course of my diagnosis and treatment.

Signature of patient (or person authorized to sign for the patient):

If authorized signer, relationship to patient:

I have been offered a copy of this consent form

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Dr. Shamsi or insurance company to release any information required to process my claims.

Patient/Guardian Signature:

To ensure our patients are compliant with their treatment plan, we have instituted a policy of drug testing in accordance with the most recent medical literature on this subject. All patients receiving prescriptions will be subject to random drug screening. Failure or refusal to produce a sample at the time requested will disqualify you from receiving further prescriptions from this practice. We send all of our samples to a certified laboratory for confirmation. If results are inconsistent with your treatment plan at any time, we reserve the right to discontinue treatment. It is your responsibility to take your medications as prescribed. Inconsistent results include the presence of illicit substances, the presence of medications not prescribed to you or the absence of medications prescribed. Do not try to manipulate the test. Current drug testing methods are very sophisticated and measure the prescribed medications as well as metabolites. The laboratory will be able to differentiate between samples that are consistent with treatment plans and samples that have been tampered with. Any confusing results will be interpreted as inconsistent. If you are taking your medication as prescribed, there should not be any confusion in the results.

We understand there is a cost associated with testing. Unfortunately, this is now a necessary part of therapy.

We understand that some of our patients are elderly or incapacitated and obtaining a sample can be inconvenient. Unfortunately, we cannot and do not discriminate on the basis of age, sex, race, nationality, religious or sexual orientation and all patients will be subject to this policy. The intent of this policy is to protect the patient, the physician, the therapy and society.

Remember the use of these potent prescriptions is a privilege. As a patient it is your responsibility to use your medication as prescribed. It is unlawful to sell or give your medication away. It is your responsibility to keep your medicine secure and away from children or others who may misuse or divert it. This policy may be amended in accordance with new medical findings or legislature mandates.

The following are a few terms that you should be familiar with that will cause you to be disqualified from receiving prescriptions from this practice.

Abuse – The willful misuse of medications, for example, to get high.

Overuse – Taking more medication than prescribed.

Diversion – Unlawful channeling of regulated pharmaceuticals from legal sources to the illicit market. Illicit – Not legal or lawful; illegal

Print Signature:

Your psychiatrist has recommended the use of medication to address your mental health symptoms. Please read the following statement. Your signature below indicates that you have read the following and have had the opportunity to discuss your concerns or questions with your psychiatrist.

1. I have been educated about the prescribed medication. I have been informed of the advantages, disadvantages, side effects and alternatives to this medication. I understand that taking this medication is strictly voluntary
2. I have had the opportunity to discuss the proposed treatment with my psychiatrist and have had the opportunity to have any questions answered to my satisfaction.
3. I understand that my psychiatrist believes that this medication is likely to help me but is unable to give a guarantee of its effectiveness.
4. I understand that all medicine comes with a risk of side effects and some side effects are rare, unpredictable and potentially harmful or deadly.
5. I understand that medicines can have an adverse effect on pregnancy and that all efforts should be made to avoid pregnancy during medication treatment. Should l become pregnant while on medicine, I understand I must contact my psychiatrist immediately to discuss the potential risks to myself, the pregnancy and the baby. I also understand that obstetricians should be informed that you have been on medications
6. I understand that I should inform the doctor or contact the office staff if there are any problems, reactions, and /or changes in my condition which may be related to this medication.
7. I understand that any written patient information available through this office is selective for its use as an educational aid and does not cover all the possible uses, actions, precautions, side effects, or interactions with this medication. It is not intended as medical advice for individual problems.
8. Some medications require periodic lab work to monitor blood levels or / to screen for possible negative effects on major organ systems of the body. Once ordered it is my responsibility to follow through on getting the ordered blood work complete. Failure to do so could potentially put me at risk for harm.
9. I understand that this consent allows other Psychiatrist and Nurse Practitioners working in coordination with Dr. Shamsi to prescribe medications as clinically indicates if Dr. Shamsi is not available.

Psychiatrist Signature:

Patient and/or Parent Signature for minor:

Patient/Representative Signature:

Patient/Representative Signature:

Patient Signature:

Guardian’s Signature:

Patient Signature:

Guardian Signature:

I hereby authorize MUHAMMAD NADEEM SHAMSI P.C. to disclose / obtain protected medical information as described below from the records of:

I understand that:

The information to be disclosed:

Uses and disclosures of protected health information

Your protected health information 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, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information 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. For example, your protected health information 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.

Treatment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Treatment: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. You may also choose to opt back in.

We may use or disclose your protected health information in the following situations without your authorization. These situations include as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes.

You may revoke the 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.

The following are statements of your rights with respect to your protected health information

You have the right to inspect and copy your protected health information (fees may apply) – Pursuant to your written request, you have the right to inspect or copy your protected health information whether in paper or electronic format. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.

You have the right to request a restriction of your protected health information – This means you may ask us not to use or disclose any part of your protected health information 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 your requested restriction except if you request that the physician not disclose protected health information to your health plan with respect to healthcare for which you have paid in full out of pocket.

You have the right to request to receive confidential communications – You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You have the right to request an amendment to your protected health information – 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.

You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of the request.

You have the right to receive notice of a breach – We will notify you if your unsecured protected health information has been breached.

You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.

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 with us by notifying our Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. Please sign the accompanying “Acknowledgment” form. Please note that by signing the Acknowledgment form you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.

Signature of Patient, Parent/Legal Guardian:

I authorize Muhammad Nadeem Shamsi, P.C to keep my signature on file and to charge the credit card selected below for the following the balance remaining after claim(s) is (are) resolved.

Cardholder Signature: