Name

First Name

Last Name

Gender

DOB

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Cell Phone

(###)

###

####

Social Security Number

Medicare ID Number

Secondary Insurance

ID Number

Prescription Plan

ID Number

Primary Contact Info

Name of primary contact

Relationship to the patient

Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Name of secondary contact

Relationship to the patient

Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Referred by

Name of primary care provider

Reason for this consultation

Patient's place of birth

Education level

Military service

Type of employment

If retired, when

YYYY

Marital / Relationship status & How long

Children and ages (seperated by a comma)

Parents, age & cause of death (if applicable)

Siblings, age & cause of death (if applicable)

Mentionable instances of family psychiatric history

If the patient has seen a psychiatrist or neurologist before, why?

Medical history (e.i. heart, lungs, thyroid, blood, arthritis, diabetes, hearing loss, vision. issues, stroke, lyme disease, COVID-19, head trauma, etc.)

Hospitalizations

MRI or CT scan history, where and when (if applicable)

Drinking quantity and history

Smoking quantity and history

Cannabis quantity and history

Check activities that the patient requires help with

Walking

Bathing

Dressing

Paying bills

Cooking

Laundry

Cleaning

Taking medication

Shopping

Who helps with these activities?

Are you basically satisfied with your life?

Have you dropped many of your interests and activities?

Do you feel your life is empty?

Do you often get bored?

Are you in good spirits most of the time?

Are you afraid something bad is going to happen to you?

Do you often feel helpless?

Do you prefer to stay at home or going out and doing new things?

Do you feel that you have more memory problems than most

Do you think it's wonderful to be alive now?

Do you feel worthless in your current state?

Do you feel full of energy?

Do you feel your situation is hopeless?

Do you think most people are better off than you?

Name of person completing this form

Relationship to the patient

Advanced Directive

(Select the one that applies)

Full code

Do not intubate

Do not resuscitate

Healthcare Proxy or Power of Attorney

First Name

Last Name

Medications

Please remember that it is your responsibility to monitor your medication usage and to plan for your follow-up visits prior to needing refills. The clinicians do not consider it an emergency if you run out of medication as a result of a cancelled or missed follow-up visit. If you arrive at the office without an appointment, an appointment will be scheduled for you, and you will be asked to return at that time. Please plan your monthly follow-up visits accordingly, taking holidays, weekends, and other non-clinic days into consideration. Please allow for up to three business days for medication refills and always check with your pharmacy first to see if they have your medications. There will be no controlled substance refills done without appointments. Patients on a controlled substance may not receive controlled substances from other providers outside of East End Neuropsych without prior notice and approval. All patients are subject to random toxicology screenings at the patient’s expense. Office Hours Are: Monday to Thursday, 9 AM–5 PM Closed Friday, Saturday, and Sunday All matters should be handled within your scheduled session times. Medication and treatment plan changes must be done during appointments only. The on-call system is for emergency use only, and repeated overuse for non-emergencies can result in patient termination. Normal visit fees and co-pays may be charged for all after-hours phone calls. No forms, external evaluations, or applications will be completed outside of an appointment. This is a legal requirement and cannot be waived. I have read and understood the information above, including the controlled substance policy and on-call fees. I agree to the responsibilities and the terms of my treatment as outlined above.

Name of Primary Physician

Medication Allergies

Pharmacy

List all your medications, their doses & the prescriber

Billing & Insurance Policy

At East End Neuropsych P.C., we participate in Medicare only. We do not accept Medicaid or other insurances. You will need to pay deductibles and applicable copayments. For those patients who are 65+ without straight Medicare, payment is due at the time of service at the full Medicare-approved rates. Patients who are covered by Medicare are responsible for their deductibles, copayments, and any non-covered services provided. East End Neuropsych P.C. is not a provider with my insurance; therefore, I will be responsible for all charges incurred at the time of the visit. A full fee scale is posted in the office and can be provided upon request. We will require a form of payment on file with the office. You may be sent to collections if there is a balance past 60 days. No forms, evaluations, or paperwork of any kind will be completed without an appointment. This is a legal requirement and cannot be waived.

I understand these terms

Missed Appointment and Cancellation Policy

Please be advised that we require 24 hours’ notice for canceled appointments, or you will be charged a missed appointment fee. No further appointments will be made until this fee is paid, and no prescriptions or forms will be completed. Missed appointment fees are $75.00 for routine appointments, $250.00 for new evaluations, and $150.00 for ketamine infusions. As a reminder, we are happy to confirm your appointments, but this confirmation call is a courtesy. You are still responsible for attending your appointment or canceling prior to the 24-hour period before your appointment. Repeated failure to keep appointments is grounds for termination from the practice. Your time slot is reserved for you alone.

I understand these terms

Disclosure of Protected Health Information

I give permission for East End Neuropsych P.C. to disclose protected health information (including mental health diagnosis, lab results, and treatment plan recommendations) to the following person(s) until further notice. This information can be released in person, via phone, through the patient portal, or by U.S. mail. I will not hold East End Neuropsych liable for the use and release of this information if made to the following parties:

I understand these terms

How would you like to receive appointment confirmations?

If at any time you would like to change the way you receive appointment confirmations, you have the right to do so. Confirmations are a courtesy; any appointment canceled within 24 hours or missed will be subject to the missed appointment fee. Only one party can be notified of an appointment through the automated system.

Phone call

Text message

Payment Agreement and Credit Card on File

I agree to be responsible for any copayments, missed appointment fees, and deductibles for services rendered by the clinical staff of East End Neuropsych P.C. and Eric Spronz, Psychiatric Nurse Practitioner P.C. I have been made aware of the missed appointment fees of $75 for a 15-minute routine visit, $150 for a missed visit, and $250 for a new patient evaluation. These time slots are reserved for me alone. East End Neuropsych never double-books patients with providers. I agree to have my credit card information kept on file to cover any balance that may be due. Charges will be processed on the day the service is rendered, including any applicable late cancellation fees. Credit card information is stored only on our HIPAA-secure platform. Accepted Cards: Mastercard, American Express, Discover & Visa

Credit card number

Expiration date

CVC (3 digits on the back of the card)

Name of cardholder

Address of cardholder

Audio Recording and AI Transcription Consent Policy

Purpose At Eric Spronz, Psychiatric Nurse Practitioner P.C. d/b/a East End Neuropsych, we aim to provide accurate and efficient medical documentation to enhance the quality of your care. To achieve this, we utilize audio recording and AI transcription technology, powered by Nextvisit AI or a similar AI provider, during medical consultations. This document outlines the process and seeks your informed consent. Recording only takes place in the clinician’s office space. Policy Overview Audio Recording Process All medical consultations at Eric Spronz, Psychiatric Nurse Practitioner P.C. d/b/a East End Neuropsych may be audio recorded to assist with accurate documentation of your medical care. Only audio content relevant to your medical consultation will be captured. Non-medical discussions or personal information unrelated to the session will not be recorded. There is no recording in common areas such as the waiting room, reception area, or restrooms. Use of Transcription Services Audio recordings will be transcribed using Nextvisit AI, a trusted third-party provider specializing in medical transcription. The AI provider may change without notice. Data Security All recordings will be securely stored and encrypted to protect your privacy and confidentiality. Access to recordings will be limited to authorized healthcare professionals directly involved in your care and Nextvisit AI personnel responsible for transcription services. Retention and Deletion of Recordings Recordings will be retained for 30 days from the date of the session to allow for transcription and review. After 30 days, recordings will be permanently deleted from the system to ensure compliance with privacy regulations. Patient Rights You will be informed about the audio recording process before the start of your session. You have the right to decline audio recording. If you choose not to consent, alternative documentation methods will be used. You may request the deletion of your audio recordings at any time, even within the 30-day retention period. Such requests will be promptly addressed in accordance with applicable privacy laws. Acknowledgment and Consent By signing below, you acknowledge that you have read and understood this policy and provide your consent for audio recording and transcription as outlined. You also understand that this consent is voluntary and may be withdrawn at any time by notifying your healthcare provider in writing. Signs are posted in each office. By speaking in the session, you and other parties present at your request consent to the use of audio records, electronic medical records, and AI use. Should you have any questions or concerns about this policy or the transcription process, please feel free to ask your provider.

I consent to the audio recording of my medical consultations for transcription purposes as described in this policy.

I do not consent to the audio recording of my medical consultations.

I have read all the policies in this package (AI, HIPAA, Medication Policy, Missed Appointment Fee, Controlled Substance Policy, Use of the On-Call System). I understand that exceptions will not be made, and all policies are subject to change. Any changes will be posted on www.eastendneuropsych.com.

I understand these terms

patient information sheet

Phone: (631)-737-6434 | Fax: (631)-738-1226