Patient Name: ______________________

Child 1

Welcome to Focus-MD!

We give our full attention to children with Attention Deficit Hyperactivity Disorder (ADHD) and their families; and, address the challenges that go along with it. Our evaluation looks at the whole person and we want to begin to get to know you before you arrive for your first visit! Please fill out the forms that follow completely and feel free to give as much information as needed. Having this information before your appointment helps us use the time at your visit to better address your concerns. We combine the information in this packet and the information you provide during your appointment, with our FDA cleared state-of-the-art objective testing to help arrive at a more accurate diagnosis. Whether your child is ultimately diagnosed with ADHD and/or some related condition, we provide support and recommendations to help you address your concerns. Again, we care about the whole child, not just the diagnosis. If ADHD treatment is needed we will explain our recommendations and provide the same careful attention to treatment that we do when making a diagnosis. When medication is recommended we will work with you to find the right solution. You do not want your child to struggle with medication side effects, and at Focus-MD we don’t want that either! Response to medication varies significantly from one person to another and our solution helps find the optimal dose of the right medication for your child. Medication is usually an important part of treatment and often the first step. But, Focus-MD is about more than medicine. We are growing our resources to help with ADHD challenges that medication alone may not improve. Finally, Focus-MD provides careful follow-up to ensure that your child is making progress in reaching their goals. We will discuss a follow-up plan with you during your first visit. Thank you for choosing Focus-MD. We are committed to taking you and your family “from frustration to focus”.

Patient Name: ______________________

Child 2

Patient Information Sheet Patient Information

First:_____________________________Middle: _________________ Last Name:

________________________

Nickname: (if applicable) _______________________ Date of Birth: __________________

o Male o Female

Mailing Address_______________________________________________________________________

City: _______________________________________ State: _________ Zip Code: __________________

Patient Email Address: ________________________________________________________________

Employer/School:_____________________________________________________________________

Cell Phone: ____________________ Home Phone: _________________

Work Phone: _________________

o I would like to receive Focus-MD newsletters, updates, and health information.

How did you hear about Focus-MD? � Friend/Relative � Doctor Referral: _______________________

� Facebook � Internet Search/Google � Internet Ad

Parent/Spouse/Emergency Contact Information

Name of Parent/Spouse/Legal Guardian: ________________________________

Cell #: ___________________

Relationship to patient: _____________________________

Is Mailing Address same as patient address? o Yes o No If no, please provide address below:

Mailing Address: _______________________________ City: ___________________ State: ____

Zip: ________Email: _____________________________________________________

Is the above listed parent/guardian responsible for patient account? o Yes o No

If no, please list below:

Patient Name: ______________________

Child 3

Responsible party: ___________________________ SS # ____________________

Date of Birth: __________

Mailing Address _______________________________City: ___________________ State: ____

Zip: ________

Insurance Information

Insurance Carrier: _______________________________________ ID #: ______________________

Group #: _____________________________ Policy Holder’s Name _________________________

Policy Holder’s Date of Birth: _________________ Relationship to patient _____________________

Policy Holder’s Social Security # _______________

Secondary Insurance Information

Insurance Carrier: _______________________________________ ID #: ______________________

Group #: _____________________________

Policy Holder’s Name ___________________________________

Policy Holder’s Date of Birth _________________ Relationship to patient _____________________

Policy Holder’s Social Security # ______________

Patient Name: ______________________

Child 4

Primary Care Physician

Name _____________________________ Phone ______________ Fax _________________

Address ____________________________ City _________________ State ____ Zip __________

Name of Referring Medical Professional

Name _____________________________ Phone _______________ Fax__________________

Address ____________________________ City ____________________ State ______ Zip________

Preferred Pharmacy

Name ______________________________Phone____________________ Fax ________________

Address _____________________________City ____________________ State ______ Zip _______

________________________________________ ______________________________

Patient (if over 18) or Guarantor Signature Date

Patient Name: ______________________

Child 5

Help Us Get to Know Your Child

Parents, please have your CHILD complete this questionnaire BY HAND or ask questions and quote answers directly if child can’t complete independently. We use this as a writing sample for the child. What do you do well?

What do you enjoy doing most?

What is your favorite thing about school?

What is your least favorite thing about school?

Is it hard for you to sit still?

Is it hard to wait your turn? If you have to wait in line, or if you want to give an answer, is that hard for you? Does your teacher think you talk too much?

Is it hard to pay attention to the teacher?

Is it hard to keep up with things like pencils, books, jackets, or sports equipment?

Is homework hard to finish?

Do you or your parents ever cry or yell over doing homework?

Do you have a good friend at school?

Do you worry a lot?

Are you sad a lot?

Patient Name: ______________________

Child 6

PATIENT HISTORY • Name of person completing this form:

Relationship to patient: _____________________

• What are your main concerns regarding the patient?

i.e. inattention, distractibility, hyperactivity, impulsivity, academic problems, oppositional

behaviors, etc.

Patient Name: ______________________

Child 7

REVIEW OF SYSTEMS: Check all that apply. Constitutional

� Problems Falling Asleep/Staying Asleep � Decreased Appetite at Lunch � Fatigue � Excessively Sleepy � Tired � Decreased Appetite � Weight Gain � Weight Loss

Eyes � Frequent Blinking/Squinting � Vision Problems � Itching/Rubbing

Ears/Nose/Throat � Large Tonsils � Snoring � Hearing Loss

Respiratory � Frequent Cough � Cough at Night/Wakes Patient � Short of Breath � Tightness in Chest � Trouble Breathing

Heart/Vascular � Chest Pain � Palpitations � Heart Racing/Fast Heart Rage � High Blood Pressure

Gastrointestinal � Frequent Abdominal Pain � Diarrhea � Stool Leakage/Accidents � Constipation � GERD/Reflux/Frequent Heartburn � Vomiting � Blood in Stool

Genito/Urinary � Bet Wetting � Urine Accident/Incontinence � Frequent Urinating � Irregular/Heavy Periods � Significant Menstrual Pain

Skin/Hair/Nails � Sores or Rashes � Hair Loss � Eczema � Acne � Twirls or Pulls Hair/Picks at Skins or Nails

Neurological

� Frequent Headaches � Verbal Tics – Sniffing, Throat Clearing,

Vocalizing � Motor Tics – Blinking, Jerking � Tremor � Blank Staring Spells � Seizures � Weakness

Musculoskeletal � Limp or Gait Disturbance � Clumsy � Joint Pain

Endocrine � Diabetes � Problems with Growth/Short Stature � Frequent Urination/Drinks Excessive Fluid � Thyroid Problems

Heme/Lymph � Anemia � Easily Bruised

Allergic/Immunologic � Food Allergy � Asthma � Allergies

Psychiatric � Anxious, Worries � Sensory Issues –Hates Tags, Socks are

Bothersome, Problems with Food Textures, Dislikes Loud Noises

� Obsessive Compulsive Behaviors � Rigid, Inflexible � Depressed, Sad � Irritable, Touchy � Mood Issues Related to Menstrual Period � Flat Effect/Zombie Like � Frequent Anger � Aggression � Paranoid, Hears Voices/Sees Things Others

Don’t � Special Abilities � Apathetic/Lazy � Low Self Esteem � Racing Thoughts � Thoughts of Self Harm, Suicide � Attempts at Self Harm, Suicide � Cutting Behavior � Hypersexual Behavior � Overly Confident or Grandiose � Not Sleeping for Over 24 Hours

Patient Name: ______________________

Child 8

ALLERGIES: Does the child have any drug allergies? o Yes o No If so, please name and describe the reaction: ______________________________________ The reaction is o Mild o Moderate o Severe Does the child have any food allergies? o Yes o No If so, please name and describe the reaction: ______________________________________ The reaction is o Mild o Moderate o Severe CURRENT ADHD MEDICATIONS: ADHD Medication Name: _______________________________ Dose: _____mg #tabs/caps _________ time taken ____:_____ am pm How effective is this medication? o not effective o somewhat effective o effective o very effective I take this medication: o Almost if not every day o School/work days o Less than 5 days a week This medication lasts: o < 6 hours o 6-8 hours o 8-10 hours o 10-12 hours The duration of the action is: o adequate o not adequate ADHD Medication Name: _______________________________ Dose: _____mg #tabs/caps _________ time taken ____:_____ am pm How effective is this medication? o not effective o somewhat effective o effective o very effective I take this medication: o Almost if not every day o School/work days o Less than 5 days a week This medication lasts: o < 6 hours o 6-8 hours o 8-10 hours o 10-12 hours The duration of the action is: o adequate o not adequate CURRENT OCD/ANXIETY/MOOD MEDICATIONS: Medication Name: ___________________________ Dose: _____mg #tabs/caps _________ time taken ____:_____ am pm How effective is this medication? o not effective o somewhat effective o effective o very effective I take this medication: o Almost if not every day o School/work days o Less than 5 days a week Side Effects (if any): ___________________________________________________________________ OTHER CURRENT MEDICATIONS: _______________________________________________________________ PAST ADHD MEDICATIONS IN LAST 2 YEARS: Medication Name: ____________________________ Dose: _____mg _____ Side Effects (if any): ___________________________________________________________________ How effective was this medication? o not effective o somewhat effective o effective o very effective Medication Name: ____________________________ Dose: _____mg ____ Side Effects (if any): ___________________________________________________________________ How effective was this medication? o not effective o somewhat effective o effective o very effective Medication Name: ____________________________ Dose: _____mg _______

Patient Name: ______________________

Child 9

Side Effects (if any): ___________________________________________________________________ How effective was this medication? o not effective o somewhat effective o effective o very effective FAMILY HISTORY: Please indicate with a √ if any of your immediate family members have experienced any of the

following conditions. Initial if none: ______

Age Career Employer/School Mother Father Sibling 1 M/F Sibling 2 M/F Sibling 3 M/F

Mother Father Sibling Sibling 2 Grandparent Aunt/Uncle

ADHD

Learning Disorder

Anxiety

Panic Disorder

OCD

Mood Disorder

Bipolar Disorder

Depression

Schizophrenia/Nervous Breakdown N

Tics/Tourette’s

Headache/Migraines

Autism/Asperger’s

Seizure Disorder

Addiction/Substance Abuse

Heart Disease Under Age of 40

High Blood Pressure

Stroke

Diabetes

Cancer

Asthma

Patient Name: ______________________

Child 10

MEDICAL HISTORY: Newborn History

• Were there any pregnancy complications? � Yes � No

� Preterm Labor � Meds During Pregnancy � Drug/Alcohol use During Pregnancy

� Other Exposure During Pregnancy � Infection During Pregnancy � Hypertension � Diabetes

Fertility Assistance Yes/No

• Length of pregnancy? � Term � Premature � Overdue � Induced # Weeks: ____________

• Birth Hospital __________________ Birth Weight _________

• Type of delivery: � C-Section � Vaginal � Vacuum Assisted � Forceps Assisted �

Meconium

• Were there any delivery complications? � Yes � No

� Difficult Delivery � Nuchal Cord � Hemorrhage

• Were there any problems after delivery? � Yes � No

� Jaundice � Breathing Problems � Bleeding in Brain � Bowel Problems � Sepsis/Infection

Infant History

Temperament *Happy *Fussy *Active *Quiet *Colic

*Social with People *Anxious around people

Nutrition * Breast Milk *Regular Formula *Special Formula (Brand) ________________

Sleep *Good sleeper *Sleep difficulty *Easy to Soothe *Hard to Soothe

Toddler History

Please mark all that apply: *Typical interests *Special interests ________

*Quiet *Separation difficulty *Active *Very Active *Scary

active *Explosive tantrums.

Preschool History

*Cooperative with Teachers/Children *Difficult with Teachers/Children

*Good with letters/numbers/colors/rhymes

*Trouble with letters/numbers/colors/rhymes

Patient Name: ______________________

Child 11

Developmental History:

Please mark when the child achieved the following milestones (E = early, A = average, or L = late) when compared to others his/her age (explain if late):

• Speech/Language (single words, sentences)

• Fine Motor Skills (stacking blocks, thumb-finger grasp, drawing circle)

• Gross Motor Skills (rolling over, standing, walking)

• Toilet Training

Has there been any regression? _______________________________________________________

Sleep History: • Does the child have a history of sleeping problems? (since infant/toddler years) � Yes � No

� Trouble Falling Asleep � Trouble Staying Asleep � Sleep Walking � Talking in Sleep

� Frequent Nightmares � Frequent Night Terrors � Vivid Dreams

• Has the child gone longer than 24 hours without sleep? � Yes � No If yes, did the child seem tired the next day? � Yes � No How often has this occurred? _______________ What is the maximum number of days the child has gone without sleep? _______________

• Does the child sleep after school? � No � Yes, Daily � Yes, Occasionally How long does he/she sleep? _____________

• Does the child seem tired during the day? � Yes � No • Does the child fall asleep during the day? � Yes � No

Behavioral/Mental Health History: • Has the child ever been formally diagnosed with ADHD? � Yes � No

If yes, when was he/she diagnosed and by whom? • Do you have documentation of the diagnosis? � Yes � No • Is he/she currently under a provider’s care for ADHD? � Yes � No Why are you changing ADHD providers? ___________________________________________

• Has the child ever received IQ or Academic Testing? � Yes � No • Diagnosed with � Dyslexia � Learning Disability �Other Diagnosis

___________________________ • Has the child ever participated in counseling, behavioral modification, or therapy? � Yes � No

If so, please explain:

______________________________________________________________________________

_____________________________________________________________________________

Patient Name: ______________________

Child 12

• Has the child every experienced any of the following conditions or symptoms?

• Depression (sad, irritable, hopeless, tearful, lack of interest, social withdrawal) � Yes � No • Anxiety (worry, fearful, obsessive thoughts, frequent headaches/stomach aches) � Yes � No • Behavioral problems (defiance, argumentative, refusals, anger, aggression,

school suspensions or detentions) � Yes � No • Verbal tics (throat clearing, repeating words) � Yes � No • Motor tics (blinking, face muscle twitching) � Yes � No

General Medical History

• Has the child been hospitalized? � Yes � No

If yes, please explain:__________________________________________________________

• Has the child ever had a concussion or head injury? � Yes � No If yes, date: _________

• How is the child’s vision? � Normal � Vision impairment � Wear corrective lenses or

contacts

• How is the child’s hearing? � Normal � Some hearing impairment � Uses hearing aid

Please check if the child has ever experienced any of the following symptoms or conditions:

Surgical History

• Tubes � Yes � No # Sets _________ 1st set at what age? _________ • Adenoidectomy � Yes � No • Tonsillectomy � Yes � No • Appendectomy � Yes � No • Other surgery: ____________________________________________________

□ Heart Murmur □ Cardiac Abnormality □ Asthma/Allergies

□ Enuresis (daytime accidents) □ Bedwetting □ Encopresis (soiling w/stool)

□ Constipation/Diarrhea □ Thyroid Problems □ Frequent Ear Infections

□ Seizures □ Reflux □ Headaches/Migraines

□ Diabetes Other:

Patient Name: ______________________

Child 13

SOCIAL HISTORY:

• Is the patient your biological child? � Yes � No

• If adopted, when was he/she adopted (what

age)?

• Has the child ever been the victim of abuse or neglect? � Yes � No

• Parent Marital Status: � Single � Married � Divorced � Separated � Widowed �

Never married

• The patient lives with: � Parents � Mom � Dad � Mom/Step-dad � Dad/Step-mom

� Grandparent

� Other relative � Non-relative

If child does not live with both parents, how often does the child see the non-custodial

parent?

� Frequently/equally � At least weekly � Rarely � No relationship

� Every other week � Monthly � Less than monthly

• Does the child have a consistent nighttime routine? � Yes � No

� Has a TV in the bedroom � Watches TV/uses electronics before bedtime

Usual bed time: _____________ Usual wake time: __________

• Does the child have any dietary restrictions? � Yes, Explain. _________________________

� Regular diet � Vegetarian � Other __________________________

• How would you rate the child’s physical activity level?

� Very active � Active � Somewhat active � Not active/couch potato

• How many caffeinated beverages does the child drink each day?

� None � <1 � 1-3 per day � 3+ per day

• Where does the child attend school? ____________________ Grade ______

• How is the child’s academic performance? � Good � Fair � Poor � Failing/Danger of

failing

� Problems with reading � Problems with writing � Problems with math

� No Problem � Somewhat of a problem � Moderate Problem � Significant Problem

•

• How is the child’s school behavior? � Good � Disruptive � Oppositional � Meltdowns

� No problem � Somewhat of a problem � Moderate problem � Significant problem

Patient Name: ______________________

Child 14

• Does the child receive any school based accommodations? � Yes � No � Needed, but reluctant to use � Resource classroom � Individual testing � IEP � Reduced work volume � 504 Plan accommodation � Response to intervention � Extended time on testing � Informal accommodations � Testing in a quiet environment � Other: ____________________________

• Does the child have any hobbies or activities they enjoy? � Yes � No

• Sports/athletics � Hunting/Fishing/Outdoors • Music/Band � Video Games _________ Hours per day • Drama � Social Media _________ Hours per day • Martial arts � TV/Other Media _______ Hours per day • Art/Creative writing � School Clubs/Social Clubs • Electronic/Social Media time is a problem ________ Hours per day

• Describe the child’s after school routine: • Tutoring/Educational Intervention � After school care • Unstructured � Car Rider • Volunteer � Rides Bus • Homework is done after school � Homework is delayed until evening

• How is the child’s behavior at home? • Good behavior � Homework problems • Problems with time management � Oppositional behavior • Problems with task completion � Disrespectful behavior • Meltdowns � Somewhat of a problem � Moderate problem � Significant problem

• How are the child’s relationships with family members? • No unusual stress � More than usual conflict with siblings • Parent/child conflict � Step-parent/child conflict • Conflict with non-custodial parent � Conflict with custodial parent/guardian • Conflict with other family members � Somewhat of a problem � Moderate problem � Significant problem

Patient Name: ______________________

Child 15

• How are the child’s relationships with peers? • Healthy, identifies friends � Limited friendships • Doesn’t identify friends � Some conflicts • Significant conflict � Problems making/keeping friends � Somewhat of a problem � Moderate problem � Significant problem

• Have there been any bullying issues? • No problems � Child is teased/picked on • Child bullies others � Bullying is ongoing • Bullying is being addressed � Somewhat of a problem � Moderate problem � Significant problem

• Have there been any major stressors for the patient during the past year? • Family conflict � Absent parent • Peer relationships � Serious illness in the family • School performance � Death in the family • Sibling relationships � Natural disaster • Financial stressors � Loss of housing • Substance abuse in home � Other: ____________________________

Patient Name: ______________________

Child 16

Patient Name: ______________________

Child 17

HER Informant, continued

Patient Name: ______________________

Child 18

NICHQ Vanderbilt Assessment Scale—TEACHER Informant

Teacher’s Name: _______________________________ Class Time: ___________________ Class Name/Period: ________________

Today’s Date: ___________ Child’s Name: _______________________________ Grade Level: _______________________________

Directions: Each rating should be considered in the context of what is appropriate for the age of the child you are rating and should reflect that child’s behavior since the beginning of the school year. Please indicate the number of weeks or months you have been able to evaluate the behaviors: ___________.

Is this evaluation based on a time when the child ! was on medication ! was not on medication ! not sure?

Symptoms Never Occasionally Often Very Often1. Fails to give attention to details or makes careless mistakes in schoolwork 0 1 2 3 2. Has difficulty sustaining attention to tasks or activities 0 1 2 33. Does not seem to listen when spoken to directly 0 1 2 34. Does not follow through on instructions and fails to finish schoolwork 0 1 2 3

(not due to oppositional behavior or failure to understand)5. Has difficulty organizing tasks and activities 0 1 2 36. Avoids, dislikes, or is reluctant to engage in tasks that require sustained 0 1 2 3

mental effort7. Loses things necessary for tasks or activities (school assignments, 0 1 2 3

pencils, or books)8. Is easily distracted by extraneous stimuli 0 1 2 39. Is forgetful in daily activities 0 1 2 310. Fidgets with hands or feet or squirms in seat 0 1 2 311. Leaves seat in classroom or in other situations in which remaining 0 1 2 3

seated is expected12. Runs about or climbs excessively in situations in which remaining 0 1 2 3

seated is expected13. Has difficulty playing or engaging in leisure activities quietly 0 1 2 314. Is “on the go” or often acts as if “driven by a motor” 0 1 2 315. Talks excessively 0 1 2 316. Blurts out answers before questions have been completed 0 1 2 317. Has difficulty waiting in line 0 1 2 318. Interrupts or intrudes on others (eg, butts into conversations/games) 0 1 2 3 19. Loses temper 0 1 2 320. Actively defies or refuses to comply with adult’s requests or rules 0 1 2 3 21. Is angry or resentful 0 1 2 322. Is spiteful and vindictive 0 1 2 323. Bullies, threatens, or intimidates others 0 1 2 324. Initiates physical fights 0 1 2 325. Lies to obtain goods for favors or to avoid obligations (eg,“cons” others) 0 1 2 326. Is physically cruel to people 0 1 2 327. Has stolen items of nontrivial value 0 1 2 328. Deliberately destroys others’ property 0 1 2 329. Is fearful, anxious, or worried 0 1 2 330. Is self-conscious or easily embarrassed 0 1 2 331. Is afraid to try new things for fear of making mistakes 0 1 2 3

The recommendations in this publication do not indicate an exclusive course of treatmentor serve as a standard of medical care. Variations, taking into account individual circum-stances, may be appropriate.

Copyright ©2002 American Academy of Pediatrics and National Initiative for Children’sHealthcare Quality

Adapted from the Vanderbilt Rating Scales developed by Mark L. Wolraich, MD.

Revised - 1102

Patient Name: ______________________

Child 19

Patient Name: ______________________

Child 20

Patient Name: ______________________

Child 21

NOTICE OF PRIVACY PRACTICES (HIPPA) THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW THIS INFORMATION MAY BE ACCESSED

Your child’s medical record may contain personal information about their health. This information may identify them and relate to their past, present or future physical or mental health condition and related health care services and is called Protected Health Information (PHI). This Notice of Privacy Practices describes how we may use and disclose your child’s PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your child’s PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you by email or other electronic transmission, or by regular mail upon request or providing one to you at your next appointment.

How we may use and disclose health care information about your child:

For Care or Treatment: Your child’s PHI may be used and disclosed to those who are involved in their care for the purpose of providing, coordinating, or managing medical services. This includes consultation with clinical supervisors or other team members. Your authorization is required to disclose PHI to any other care provider not currently involved in their care. Example: If another physician referred your child to us, we may contact that physician to discuss your child’s care. Likewise, if we refer you to another physician, we may contact that physician to discuss your child’s care or they may contact us.

For Payment: Your child’s PHI may be used and disclosed to any parties that are involved in payment for care or treatment. If you pay for your child’s care or treatment completely out of pocket with no use of any insurance, you may restrict the disclosure of your child’s PHI for payment. Example: Your payer may require copies of your child’s PHI during the course of a medical record request, chart audit or review.

For Business Operations: We may use or disclose, as needed, your child’s PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. We may also disclose PHI in the course of providing you with appointment reminders or leaving messages on your phone or at your home about questions you asked or test results. Example: We may share your child’s PHI with third parties that perform various business activities (e.g., Council on Accreditation or other regulatory or licensing bodies) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI.

As Required by Law: Under the law, we must make disclosures of your child’s PHI available to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule, if so required.

Patient Name: ______________________

Child 22

Without Authorization: Applicable law and ethical standards permit us to disclose information about your child’s medical condition and care without your authorization only in a limited number of other situations. Examples of some of the types of uses and disclosures that may be made without your authorization are those that are:

• Required by law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations, for instance, the local or state health department.

• Required by Court Order • Required or necessary to prevent or lessen a serious and imminent threat to the

health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Verbal Permission: We may use or disclose your child’s PHI to family members that are directly involved in your receipt of services with your verbal permission.

With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked. Your explicit authorization is required to release psychotherapy notes; and PHI for the purposes of marketing, subsidized treatment communication and for the sale of such information, which practices we do not currently engage in. Your rights regarding your child’s PHI: You have the following rights regarding PHI we maintain about your child. To exercise any of these rights, please submit your request in writing to our Privacy Officer:

• Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances to inspect and copy PHI that may be used to make decisions about medical service provided. Generally, PHI we obtain from other providers active in your child’s medical care will not be released by us and may be obtained from those providers.

• Right to Amend. If you feel that the PHI we have about your child is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.

• Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your child’s PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

• Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your child’s PHI for services, payment, or business operations. We are not required to agree to your request.

• Right to Request Confidential Communication. You have the right to request that we communicate with you about your child’s PHI matters in a specific manner (e.g. telephone, email, postal mail, etc.)

• Right to a Copy of this Notice. You have the right to a copy of this notice.

Patient Name: ______________________

Child 23

Website Privacy: Any personal information you provide us with via our website, including your e-mail address, will never be sold or rented to any third party without your express permission. If you provide us with any personal or contact information in order to receive anything from us, we may collect and store that personal data. We do not automatically collect your personal e-mail address simply because you visit our site. In some instances, we may partner with a third party to provide services such as newsletters, surveys to improve our services, health or company updates, and in such case, we may need to provide your contact information to said third parties. This information, however, will only be provided to these third-party partners specifically for these communications, and the third party will not use your information for any other reason. While we may track the volume of visitors on specific pages of our website and download information from specific pages, these numbers are only used in aggregate and without any personal information. This demographic information may be shared with our partners, but it is not linked to any personal information that can identify you or any visitor to our site. Our site may contain links to other outside websites. We cannot take responsibility for the privacy policies or practices of these sites and we encourage you to check the privacy practices of all internet sites you visit. While we make every effort to ensure that all the information provided on our website is correct and accurate, we make no warranty, express or implied, as to the accuracy, completeness or timeliness, of the information available on our site. We are not liable to anyone for any loss, claim or damages caused in whole or in part, by any of the information provided on our site. By using our website, you consent to the collection and use of personal information as detailed herein. Any changes to this Privacy Policy will be made public on this site so you will know what information we collect and how we use it.

Breaches: You will be notified immediately if we receive information that there has been a breach involving your PHI. Complaints: If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at Focus-MD. If you have questions and would like additional information, you may contact your office. Focus-MD Red Bank, NJ 766 Shrewsbury Avenue Suite 400 Tinton Falls, NJ 07724 I acknowledge by signing below that I have received the Notice of Privacy Practices and Notice of Individual Rights. ________________________________________________ ____________________ Patient (if over 18) or Patient’s Personal Representative Date

Patient Name: ______________________

Child 24

CONSENT FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR PAYMENT, TREATMENT AND HEALTH CARE OPERATIONS

By signing below, you hereby consent for this Practice to use or disclose information about yourself or your child (or another person for whom you have the authority to sign) that is protected under federal law, for the sole purposes of treatment, payment and health care operations. You may refuse to sign this consent form. You should read the Notice of Privacy Practices for Personal Health Information (PHI) attached to this form before signing the Consent. The terms of the Notice may change from time to time, and you may always get a revised copy of it by asking the Privacy Officer for this Practice. You have the right to request that the Practice restrict how PHI is used or disclosed to carry out treatment, payment, or health care operations. The Practice is not required to agree to requested restrictions, however; if the Practice agrees to your requested restrictions, the restriction is binding on it. Information about you and your child is protected under federal law, and you have the right to revoke this Consent, unless we have taken action in reliance on your authorization (as determined by our Privacy Officer). By signing below, you recognize that the protected health information used or disclosed pursuant to this Consent may be subject to re-disclosure by the recipient and may no longer be protected under federal law. Please check the following if applicable: __ You may call my home and leave a message with someone or on an answering machine if I am not available. __ You may call my place of employment and leave a message on an answering machine or with someone if I am not available. __ You may call my cell phone and leave a message on my answering machine if I am not available. __ You may communicate confidential information to me, including invoices for services, to the address and/or phone numbers that is given in my patient information. If not, please indicate the address or phone number that we may use:__________________________ __You may discuss by electronic communication or phone, my child’s symptoms (if pediatric patient), diagnosis and treatment with teachers and school representatives. __ I agree to use the patient portal for questions pertaining to medication management and discussion of my child’s symptoms/side effects. __ I agree to secured communication through the patient online portal for medication management including discussion of symptoms/side effects. I realize that this communication is a part of the patient’s permanent medical record.

Patient Name: ______________________

Child 25

__I consent to disclosure of the following protected health information about me to the following family member(s) or person(s) involved in my child’s care or payment for my child’s care. Name:_________________________________________ Relationship:___________________________________ Name:_________________________________________ Relationship:___________________________________ Check all that apply to names above: __ All my child’s medical information

__ Specific medical information such as test results,

prescriptions,etc..__________________________

__ Information necessary to help my family member(s) take care of my child.

__ Information necessary to bill for or submit claims for medical care provided to my child.

______________________________________________ __________

Patient (if over 18)/Guardian Signature Date

Patient Name: ______________________

Child 26

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

Patient Name: ________________________________________________ Date of Birth: ________________________ Patient Address: __________________________________(City) ________ (State) _______ (Zip) ________ Contact Phone No: _________________________

I hereby authorize: __________________________________ (practitioner) to release/disclose my child’s health information as described below.

Practitioner’s Name: ___________________________________

Address: ________________________________________ (City) ___________

(State) ________ (Zip) ________

Office Phone: ___________________ Office Fax: ______________________

Please identify the information to be released: ____Please Release ALL Records ____Office Notes ____Testing Results ____Surveys ____Medication List The identified information will be used for the following purpose: ____Change to another Physician ____ Personal Records ____Attorney/Legal ____Continued Care (Consult/Referral) ____Other_____________________________________

Patient Name: ______________________

Child 27

Please initial each item below to indicate your understanding: ____ I understand once the information above is released, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations. ____ I understand authorizing the use or release of this information is voluntary. I need not sign this form to ensure health care treatment. ____ I understand I have a right to revoke this authorization at any time. I understand if I revoke this authorization, I must do so in writing and present my written revocation to the practice. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. The identified information may be used by or released to the following individual(s) or organization(s): This authorization will expire on (insert date or event):___________If I fail to specify an expiration date or event, this authorization will expire twelve (12) months from the date on which it was signed. Patient (if over 18)/Legal Guardian/Parent Signature: _________________________________________________ Relationship: _________________________________________ Date: _________________________________ Witness Signature: ______________________________________________ Date________________________

Focus-MD Red Bank 766 Shrewsbury Avenue

Suite 400 Tinton Falls, New Jersey 07724

Patient Name: ______________________

Child 28

Focus-MD Red Bank Financial Policy

This financial policy contains important information about payment for our professional services. It is intended to help us provide your child with the highest level of medical care and help control administrative costs for services provided. It outlines our responsibilities and those of our patient’s regarding payment for services. It is the patient’s or their legal representative’s responsibility to make payment at the time of service for all services rendered including all evaluations and testing. Our office will to the best of our ability attempt to predetermine, prior to the initial visit, what services, evaluations, and testing may be covered under the patient’s insurance benefits, but we will not guarantee the accuracy of this predetermination. The contract with insurance companies our practice participates with mandates all copays and patient responsibility payments be made at the time of service. The patient or their legal representative has a contract with your insurance carrier. Our services may or may not be covered by your particular policy. It is your responsibility to contact your carrier to determine if our services are covered under your contract prior to the date of service. A referral may be required by your insurance carrier for our services. It is your responsibility to obtain the required referral prior to the visit. Our staff is happy to help with questions relating to an insurance claim or to provide additional information requested by your insurance carrier in order for the claim to be processed. However, patients should direct questions about coverage for specific procedures to a representative of their insurance carrier’s member services department. The phone number for member services is usually located on the back of your insurance card. Our office will attempt to work with families to determine a payment plan for services at our discretion. A schedule of professional fees is available upon request. Payment for professional services may be made by cash, check, or credit/debit card. Patients 18 years old and above, who are covered under the insurance policy of the parent or guardian, must designate whether responsibility for payment will fall upon the parent/ guardian or themselves. responsibility for payment, an authorization for services must be signed by that parent or guardian.

Patient Name: ______________________

Child 29

Additional Charges for Non-Medical Services Late Cancellation/No Show Initial Evaluation or Extended Appointments $150 Late Cancellation/No Show Follow-Up Appointments $50 Accommodation Requests (Extensive) $50 Returned Check $35 Form Completion Fee (Not at Time of Service) $10 per Issue Medical Records Copies ----- $10 Administrative fee plus $1 per page for pages 1-25 /$0.50 per page for pages 26 and over I have read and understand the financial policy as stated. _____________________________________ _______________________ Guarantor Print Name (Parent/Guardian/Patient) SS # of Guarantor _____________________________________ _______________________ Relation to Patient Date _____________________________________ _______________________ Patient (if over 18) or Guarantor Signature Patient Name

Patient Name: ______________________

Child 30

NON-COVERED SERVICES POLICY

In order to provide the highest level medical care for our patients, certain medical services, evaluations, neuropsychological testing and laboratory and genetic testing that we feel are necessary for this level of care may not covered by some insurance carriers. We may determine that we can not effectively provide medical services to you and your child if these medical tests, evaluations or services are not completed. You will be expected to pay for those services in full at the time they are provided.

The below listed procedures are some of the tests/evaluations frequently used by Focus-MD providers with the appropriate procedure codes.

Patient Testing

• QbTest • CNS Vital Signs • Clinicom • Vanderbilt Assessment, NeuroPsych

Questionnaire, Adult ADHD Self-Report Scale, ADHD Rating Scale IV

• NEBA EEG Testing

Testing/Assessment Codes 96132/96138 96132/96138 96132 96127 96127

I have read and understand that charges for services not covered by my insurance plan will be my responsibility to pay in full on the day the services are rendered. Signature: _______________________________ Patient Name: _____________________________________ Date of Birth: _________ Date: ________________________________________

Patient Name: ______________________

Child 31

LATE RESCHEDULING/CANCELLATION/NO SHOW POLICY

Our provider’s time is reserved for you. We do not double book our patients in order to provide adequate time for each individual appointment. We strive for exceptional care through individual attention.

Any appointment rescheduled or cancelled less than the day before the appointment day is

considered a Late Rescheduling/Cancellation/No Show.

A Late Rescheduling/Cancellation/No Show on a new or extended patient appointment will

result in a $150 fee that is not covered by insurance.

A Late Rescheduling/Cancellation/No Show on an established patient appointment will result in

a fee of $50 that is not covered by insurance.

Exceptions to this policy will be reserved for verifiable emergencies only and will be at the sole

discretion of Focus-MD Red Bank management.

Repeated Late Rescheduling/Cancellation/No Show appointments will result in unconditional

discharge from care at this facility.

I, ________________________________, (patient/parent/legal guardian) acknowledge that I

fully understand the Focus-MD Red Bank Late Rescheduling/Cancellation/No Show policy.

____________________________________________ _______________ Signature Patient (if over 18)/Guarantor Date

Patient Name: ______________________

Child 32

Focus-MD Red Bank Credit/Debit Card Policy We welcome you to our practice. We look forward to helping your child and you understand and manage the attention, learning and associated conditions that your child faces. In order to reduce administrative costs, at the time we schedule your first appointment we will ask you for a credit/debit card which will securely be held on file and be used to process copays, patient balances, charges for evaluations and testing, and non-covered services and fees, which are not paid for in another manner at the time of service. We greatly appreciate your understanding, and will discuss with you any questions or concerns regarding this policy that you may have. I_______________________________________ (patient, if 18 or older, parent, legal guardian), acknowledge that I understand the Focus-MD, Red Bank NJ Credit/Debit Card Policy. _____________________________________ _________________ Patient (If 18 or over)/Guarantor Signature Date