Forms


forms

If you are a new Psychiatry or Psychotherapy patient, please complete, sign, and e-mail back to Dr. Ambardar the following forms before your first online visit. If you are a new Coaching client, Dr. Ambardar will e-mail you a separate set of intake forms.

(1) New Patient Evaluation Form

(2) Please read our HIPAA Notice and sign the Acknowledgement Of Receipt form.

(3) Office PoliciesPlease read and sign, paying particular attention to the first page regarding Monthly Medication Management Appointments, Late Cancellations, and No Shows.

(4)Treatment Consent Form Please read and sign, paying particular attention to the OTHER PROFESSIONAL SERVICES section as excerpted here:

Professional services such as completing prior authorizations for medications, ordering medications outside of regularly scheduled appointments, filling out forms, telephone calls, extensive e-mail conversations, preparation of treatment summaries, or time spent performing any other functions that you may request will be charged $150 for each 15 minute increment.

(5) Credit Card Authorization Form: Please read and sign.

(6) Telepsychiatry & Teletherapy Consent Form: Please read and sign.

(7) Open Payments Database Written Notice:  Please read and sign.  [For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.]

Please read about our Medication Refill Policy below before requesting a Psychiatry appointment. Thank you!

 

Office Policy