ADHD Clinic for Kids and Adults

Today is 2024/11/21
ADHD Clinic for Kids and Adults

New Adult ADHD Patient /
Family And Insurance Information Form

First Name

Last Name

Date of Birth

Age

Male Female

*Attenion: If you do not include a proper home address in the fields below, you're form will be discarded/deleted immediately. Answers such as n/a are not acceptable answers. We need a complete and accurate address to be able to bill you for our services, as well as creating a medical record for you.

Street

City

State

Zip Code

Cell Phone

Home Phone

Employer Name

Employer Address

Street

City

State

Zip Code

Work Phone

Martial Status

Emergency Contact

Full Name

Last Name

Emergency Contact Phone

Emergency Contact Relationship

Who referred you to our office?

* Please read the following statements and check the boxes if you agree.

Assignment of Benefits: I understand that I am financially responsible for all the changes for services rendered by Dr Najem, M.D. including the balance remaining after the payment of possible insurance benefits. "No-Show" policy: If you fail to cancel and fail to show up for the appointment, we may charge your account $25 "no-show" charge. I am aware of this policy and agree to pay such charges

Today's Date

Meaningful Use Form

Meaningful Use: Dr Najem would like to thank you for taking the time to complete this short questionnaire. We apologize for any inconvenience. Electronic Health Records serve as an important facilitator for collecting patient demographic data. The 2009 economic stimulus bill and 2010 health system reform bills, both strongly encourage collection of this data. Due to recent government initiatives to promote the use of electronic health records and in compliance with Meaningful Use, the reporting of the patient's racial background is now a requirement. Please complete the following information regarding the patient who is being seen today.

First Name

Last Name

Pharmacy Name

Pharmacy Phone

This office may ePrescribe (send prescriptions electronically to your pharmacy) and view my external history prescriptions (prescriptions written by other doctors).

yes

Ethnicity

How would you describe the patient's ethnicity? If you are uncomfortable answering the questions, you may select "Decline to answer".

Choose one

Language

I authorize Dr Najem MD to release any medical records when I request them to be shared.

yes

Date Signed

Draw your signature

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This practice uses and discloses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Treatment We are permitted to use and disclose your medical information to those involved in your treatment. For example, your care may require the involvement of a specialist. When we refer you to a specialist, we will share some or all of your medical information with that physician to facilitate the delivery of care. Health Care Operations We are permitted to use or disclose your medical information for the purposes of health care operations, which are activities that support this practice and ensure that quality care is delivered. For example, we may engage in the services of a professional to aid this practice in its compliance programs. This person will review billing and medical files to ensure we maintain our compliance with regulations and the law. Disclosures That Can Be Made Without Your Authorization There are situations in which we are permitted by law to disclose or use your medical information without your written authorization or an opportunity to object. In other situations we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization, in writing, to stop future uses and disclosures. However, any revocation will not apply to disclosures or uses already made or taken in reliance on that authorization.

I have read and agree with the above notice of PRIVACY PRACTICES.

yes

Questionaire

Briefly describe your symptoms

When did your symptoms start

On a scale of 1-10 (10 being the worst) rate your symptoms

Have your co-workers complained about your performance?

yes

Do you feel uncomfortable in social settings?

yes

Have you lived in a home built before 1960?

yes

How was your work/school performance?

ADD Questions

1) Fidget/squirm with your hands or feet or squirms in seat.

yes

2) Blurts out answers before questions have been completed.

yes

3) Often interrupt others during conversations

yes

4) Difficulty unwinding or relaxing when you have free time.

yes

5) Difficulty getting things done when organization is req.

yes

6) Leave your seat often during meetings.

yes

7) Trouble wrapping up the final details of a project.

yes

8) Problem remembering appointments or obligations.

yes

9) Avoid tasks when they require a lot of thought.

yes

Thank-you for filling out and submitting the form.

Resources

ADHD Medications
ADHD Suppliments
Behavioral Health Topics
Online Testing

Clinic Hours

Mon: 8am-6pm
Tues-Thurs: 12pm-6pm
Fri: 8am-2pm
Sat: 8am-12pm

Najem ADHD Clinic

26850 Providence Parkway
Suite 300
Novi, Michigan
48374
(248) 348-4200

New Adult ADHD Patient /Family And Insurance Information Form

Meaningful Use Form

Notice of Privacy Practices

Questionaire

ADD Questions

Resources

Clinic Hours

Najem ADHD Clinic

New Adult ADHD Patient /
Family And Insurance Information Form