Forms & Screening Library
Downloadable TNC forms for patient intake, clinical screening, behavioral health, consent, privacy, communication, financial, medication, and treatment workflows — connected to the operational standards staff use across Sawubona.
GLP-1 & Weight Management Forms
Patient agreements, financial forms, pricing references, dose-adjustment guidance, medication preparation workflows, and Tirzepatide patient education are now included directly in the Forms & Screening Library.
Forms Used in Clinical & Billing Workflows
These existing forms support the organization-wide standards now connected across the Billing Center, Clinical Center, Provider Resource Center, and SOP Library. Use the form here; use the connected center for the workflow and documentation standard.
GLP-1 Medication Preparation & Dispensing Workflow
Internal clinical workflow for GLP-1 medication preparation, storage, dispensing, documentation, and staff responsibilities.
GLP-1 Weight Management Program - Financial Responsibility Agreement
Patient financial agreement covering program fees, medication policy, missed appointments, and payment responsibility.
GLP-1 Weight Management Program - Clinical Protocol & Dispensing Policy
Internal provider and clinical staff protocol for patient evaluation, medication management, monitoring, and dispensing.
GLP-1 Patient Consent & Treatment Agreement
Patient consent covering treatment purpose, medical evaluation, risks, responsibilities, monitoring, and follow-up expectations.
Tirzepatide Price Sheet Proposal
Program pricing proposal and medication-cost planning reference for the Tirzepatide Weight Management Program.
Tirzepatide Weight Management Cash Program Pricing
Patient-facing cash program pricing, initial consultation details, monthly program options, and included services.
Tirzepatide Dose Adjustment Protocol
Clinical dose-adjustment and titration protocol for provider-directed Tirzepatide weight-management therapy.
GLP-1 Weight Management - Financial Agreement
Branded patient financial responsibility agreement for participation in the GLP-1 Weight Management Program.
GLP-1 Weight Management - Patient Agreement
Branded patient consent and treatment agreement for the GLP-1 Weight Management Program.
Tirzepatide Medication Bag / Patient Handout
Patient handout for medication storage, handling, and supporting Tirzepatide medication instructions.
Fall Risk Self Assessment
Branded printable TNC form.
Alcohol Use Disorders Identification Test AUDIT
Branded printable TNC form.
Ask Suicide Screening Questions ASQ
Branded printable TNC form.
Borderline Symptom List BSL 23
Branded printable TNC form.
CAGE Alcohol Abuse Screening Tool
Branded printable TNC form.
CAGE AID Substance Abuse Screening Tool
Branded printable TNC form.
Drug Abuse Screening Test DAST 10
Branded printable TNC form.
Generalized Anxiety Disorder Assessment GAD 7
Branded printable TNC form.
Hamilton Anxiety Rating Scale HAM A
Branded printable TNC form.
Mood Feelings Questionnaire MFQ Long Version Adult Self Report
Branded printable TNC form.
Mood Feelings Questionnaire MFQ Long Version Child Self Report
Branded printable TNC form.
Mood Feelings Questionnaire MFQ Long Version Parent Guardian Report
Branded printable TNC form.
MFQ Short Version Adult Self Report
Branded printable TNC form.
MFQ Short Version Child Self Report
Branded printable TNC form.
MFQ Short Version Parent Guardian Report
Branded printable TNC form.
Mood Disorder Questionnaire MDQ
Branded printable TNC form.
Opioid Risk Tool ORT Female Version
Branded printable TNC form.
Opioid Risk Tool ORT Male Version
Branded printable TNC form.
PEG Pain Screening Tool
Branded printable TNC form.
PHQ 9 Modified for Adolescents PHQ A
Branded printable TNC form.
PHQ A Combined with ASQ
Branded printable TNC form.
Pain Self Efficacy Questionnaire PSEQ
Branded printable TNC form.
Panic Disorder Severity Scale PDSS
Branded printable TNC form.
Patient Health Questionnaire PHQ 2
Branded printable TNC form.
Patient Health Questionnaire PHQ 9
Branded printable TNC form.
Patient Screening Form
Branded printable TNC form.
Pediatric Symptom Checklist 17 PSC 17
Branded printable TNC form.
Posttraumatic Stress Disorder Checklist for DSM 5 PCL 5
Branded printable TNC form.
Rapid Opioid Dependence Screen RODS
Branded printable TNC form.
Vanderbilt Assessment Follow Up Parent Guardian Informant
Branded printable TNC form.
Vanderbilt Assessment Scale Parent Guardian Informant
Branded printable TNC form.
Patient Information and Health Summary
Branded printable TNC form.
Prescriptions
Branded printable TNC form.
Counseling New Patient Form
Branded printable TNC form.
Columbia Suicide Severity Rating Scale C SSRS
Branded printable TNC form.
Consent to Treat a Minor Counseling
Branded printable TNC form.
Medical History Form
Branded printable TNC form.
Release of Information
Branded printable TNC form.
Credit Card on File Authorization Consent
Branded printable TNC form.
Medical History Preventive Screenings Form
Branded printable TNC form.
Notice of Privacy Practices HIPAA
Branded printable TNC form.
Consentimiento para Extracci n de Muestras de Laboratorio
Branded printable TNC form.
Consentimiento para Comunicaci n Electr nica
Branded printable TNC form.
Testosterone Therapy Agreement
Branded printable TNC form.
Aviso de Pr cticas de Privacidad HIPAA Espa ol
Branded printable TNC form.
Therapy Groups Disclosure Statement
Branded printable TNC form.
Patient Rights Responsibilities
Branded printable TNC form.
Formulario de Consentimiento para Telesalud
Branded printable TNC form.
Consent to Treat Unaccompanied Minor
Branded printable TNC form.
Informed Consent Contract for Controlled Substance Medications
Branded printable TNC form.
Behavioral Health Services Informed Consent
Branded printable TNC form.
How to Update Your Medical Information
Branded printable TNC form.
Consentimiento para Tratamiento
Branded printable TNC form.
Acuerdo de Responsabilidad Financiera
Branded printable TNC form.
Disclosure and Consent to Injection Treatment
Branded printable TNC form.
Consent to Treat
Branded printable TNC form.
Telehealth Consent Form
Branded printable TNC form.
Financial Responsibility Agreement
Branded printable TNC form.
Consent for AI Assisted Audio Documentation of Clinical Visits
Branded printable TNC form.
Consent for Lab Draw
Branded printable TNC form.
Electronic Communication Consent
Branded printable TNC form.
Derechos y Responsabilidades del Paciente
Branded printable TNC form.
Behavioral Health Informed Consent
Read-only RXNT consent for behavioral health services, confidentiality, telehealth, attendance, emergencies, and treatment expectations.
Collateral Participation Agreement
Read-only agreement for family members, caregivers, or other non-client participants in a behavioral health session.
Court-Involved Therapy Acknowledgment
Read-only acknowledgment defining the therapeutic role, confidentiality, custody issues, records, subpoenas, and legal requests.
Insurance Opt-Out Agreement
Read-only behavioral health agreement for a client's voluntary election not to use available insurance when permitted.
Minor Behavioral Health Records Authorization
Read-only authorization for release of a minor's behavioral health records after verification of legal authority and applicable privacy requirements.
HIPAA Authorization And Notice Of Privacy Practices Acknowledgment
Read-only HIPAA privacy acknowledgment covering treatment, payment, operations, patient rights, and separate authorizations when required.
Consentimiento Para Extracción De Sangre
Consentimiento en español para extracción de sangre y recolección de muestras de laboratorio.
Consentimiento Para Comunicaciones Electrónicas
Consentimiento en español para mensajes de texto, correo electrónico, correo de voz, portal del paciente y otras comunicaciones electrónicas.
Testosterone Therapy Agreement And Informed Consent
Read-only informed consent for testosterone therapy, risks, fertility considerations, monitoring, medication safety, and follow-up.
Autorización HIPAA Y Reconocimiento Del Aviso De Prácticas De Privacidad
Reconocimiento HIPAA en español sobre privacidad, tratamiento, pago, operaciones y derechos del paciente.
Therapy Groups Disclosure Statement
Read-only group therapy disclosure covering confidentiality, participation, privacy, telehealth, recording, and group expectations.
Patient Rights And Responsibilities
Read-only patient rights and responsibilities acknowledgment covering respectful care, informed participation, privacy, safety, appointments, and financial duties.
Consentimiento Para Servicios De Telesalud
Consentimiento en español para servicios de telesalud, privacidad, ubicación del paciente, riesgos y responsabilidades.
Consent To Treat An Unaccompanied Minor
Read-only parent or guardian consent for routine outpatient treatment of an unaccompanied minor.
Controlled Substance Treatment Agreement
Read-only controlled substance agreement covering safe use, PDMP review, monitoring, refills, storage, and treatment expectations.
Consentimiento Para Recibir Tratamiento
Consentimiento general en español para evaluación, diagnóstico, tratamiento y atención médica ambulatoria.
Acuerdo De Responsabilidad Financiera
Acuerdo financiero en español sobre seguro, copagos, deducibles, servicios externos, saldos y responsabilidad del paciente.
Disclosure And Consent To Injection Treatment
Read-only consent for medically appropriate injections, including general risks, medication-specific considerations, monitoring, and emergency guidance.
Consent To Treat
Read-only general medical consent for evaluation, diagnosis, treatment, medications, laboratory testing, referrals, and follow-up.
Telehealth Consent
Read-only telehealth consent covering location, privacy, limitations, medications, technology failures, emergencies, and patient responsibilities.
Financial Responsibility Agreement
Read-only financial agreement covering insurance, benefits verification, patient responsibility, outside services, balances, and billing.
Consent For AI-Assisted Clinical Documentation
Read-only consent for AI-assisted transcription, ambient documentation, and clinical note drafting during healthcare encounters.
Consent For Laboratory Blood Draw And Specimen Collection
Read-only consent for blood draws and other specimen collection, including risks, processing, outside laboratory billing, and follow-up.
Consent For Electronic Communications
Read-only consent for text, email, voicemail, patient portal, telephone, and other electronic communications.
Derechos Y Responsabilidades Del Paciente
Versión en español de los derechos y responsabilidades del paciente.
GLP-1 Medication Preparation & Dispensing Workflow
Standard Operating Procedure (SOP)
GLP-1 Medication Preparation & Dispensing Workflow
Department: Clinical Operations
Applies To: Providers, Nursing Staff, Medical Assistants, Clinical Leadership
Purpose
To establish a standardized process for the safe handling, preparation,
documentation, and dispensing of GLP-1 medications provided through the
clinic’s medical weight management program.
Scope
This SOP applies to all staff members involved in receiving, storing, preparing,
documenting, and dispensing GLP-1 medications.
• Semaglutide
• Tirzepatide
Patient Eligibility Requirements
Provider evaluation completed☐
Patient approved for treatment☐
Consent form completed☐
Financial agreement completed☐
Required follow-up appointments completed☐
Medication remains clinically appropriate per provider documentation☐
Medication Storage & Inventory Management
Maintain medication inventory according to manufacturer guidance and
clinic policy.
Monitor expiration dates.
Document medication receipt and inventory changes.
Store medications securely with restricted access.
Maintain appropriate temperature and storage requirements as applicable.
Medication Preparation Process
Medication preparation shall only be performed by authorized trained staff.
Follow approved clinic procedures.
Follow manufacturer guidance and applicable regulatory requirements.
Verify medication name, concentration, patient information, and
expiration information.
Maintain clean preparation practices.
Complete required documentation for each preparation batch or patient
supply.
Quality Verification
Correct patient☐
Correct medication☐
Correct prescribed dose☐
Appropriate labeling☐
Expiration information documented☐
Provider order verified☐
Patient instructions provided☐
Dispensing Workflow
Confirm patient identity.
Confirm required visit completion.
Confirm provider authorization.
Review medication instructions.
Provide appropriate education and reminders.
Document medication dispensing.
Monthly Monitoring Requirements
• Weight
Blood pressure
• Pulse
Medication tolerance concerns
Reported side effects
Patient questions or concerns
Findings requiring provider review should be escalated appropriately.
Documentation Requirements
Medication name
Patient name
Date dispensed
Quantity provided
Provider authorization
Staff member completing dispensing
Patient education provided
Safety Concerns & Escalation
Significant adverse reactions
Medication concerns
Incorrect medication concerns
Patient reports of concerning symptoms
Questions regarding eligibility or continuation
Compliance
All staff participating in this program must follow this SOP and complete required
training prior to performing medication-related duties.
Clinic leadership will periodically review workflow, documentation, and
compliance requirements.
GLP-1 Weight Management Program - Financial Responsibility Agreement
GLP-1 Weight Management Program
Financial Responsibility Agreement
Program Overview
The GLP-1 Weight Management Program provided through this clinic includes
provider evaluation, ongoing medical monitoring, medication management, and
medication dispensing as appropriate.
This program is a self-pay service unless otherwise communicated by the clinic.
Program Fees
Initial Evaluation: $_____________
Monthly Medication Program Fee: $_____________
Follow-Up Provider Visit: $_____________
Additional Services (if applicable): $_____________
Fees are due at the time services are rendered unless other arrangements have
been approved by clinic leadership.
Payment Responsibility
I am financially responsible for program fees.
Insurance coverage is not guaranteed and may not apply to program-
related services or medications.
Payment is required regardless of treatment outcome.
Weight-loss results cannot be guaranteed.
Medication Policy
Medication will only be provided after provider approval.
Medication availability is dependent on clinic supply and applicable
requirements.
Medication cannot be dispensed without completion of required visits and
documentation.
Medication cannot be returned, exchanged, or refunded once dispensed
unless required by applicable law.
Missed Appointments
Monthly appointments are required to continue receiving medication.
Missed appointments may result in delayed medication dispensing.
Repeated missed appointments may result in removal from the program.
Cancellation & Refund Policy
Fees paid for completed medical evaluations, provider services, and
dispensed medications are non-refundable.
Program fees do not guarantee a specific amount of weight loss.
The clinic reserves the right to discontinue treatment when medically
appropriate.
Patient Agreement
By signing below, I acknowledge that I have reviewed and understand the
financial responsibilities associated with participation in the GLP-1 Weight
Management Program.
GLP-1 Weight Management Program - Clinical Protocol & Dispensing Policy
GLP-1 Weight Management Program
Clinical Protocol & Dispensing Policy
Applies To: Providers, Medical Assistants, Nursing Staff, Clinical Leadership
Purpose
To establish a standardized process for evaluating, initiating, dispensing, and
monitoring GLP-1 medications offered through the clinic for medical weight
management.
Scope
This protocol applies to all patients participating in the clinic's GLP-1 Weight
Management Program and all clinical staff involved in patient care, medication
preparation, dispensing, and follow-up.
Current medications available through this program may include, but are not
• Semaglutide
• Tirzepatide
Additional medications may be added as approved by clinic leadership.
Initial Patient Evaluation
Prior to initiating therapy, each patient shall complete an in-person medical
evaluation performed by a licensed provider .
Complete medical history
Current medication review
Weight history
BMI calculation
Vital signs
Relevant comorbidities
Contraindication screening
Pregnancy screening when applicable
Discussion of treatment goals
Review of potential risks, benefits, side effects, and alternatives
The provider will determine whether the patient is an appropriate candidate for
GLP-1 therapy.
Required Documentation
Medical intake paperwork
Weight management questionnaire
Medication reconciliation
Provider evaluation
GLP-1 informed consent
Financial responsibility acknowledgment
HIPAA documentation
Any additional forms required by clinic policy
Treatment Initiation
The provider will prescribe the appropriate medication and dosing
schedule.
Medication will be prepared and dispensed by clinic personnel in
accordance with applicable regulations, manufacturer guidance, and clinic
procedures.
Patients will receive education regarding:
o Injection technique
o Storage requirements
o Missed doses
o Potential side effects
o Expected weight-loss progression
o Nutrition recommendations
o Exercise recommendations
o When to contact the clinic
Monthly Follow-Up Visits
Patients are required to return to the clinic every 30 days.
• Weight
Blood pressure
• Pulse
Review of side effects
Medication tolerance
Review of adherence
Assessment for dose adjustments, if appropriate
Dispensing of the next month's medication supply
Medication will not be dispensed without an appropriate follow-up visit unless
otherwise authorized by the provider .
Quarterly Provider Follow-Up
Every three months, patients must be evaluated by their provider .
Total weight loss
BMI changes
Waist circumference (if applicable)
Medication effectiveness
Lifestyle modifications
Side effects
Laboratory monitoring, when indicated
Continued eligibility for treatment
Need for dosage adjustment
Decision to continue, modify, or discontinue therapy
Patient Responsibilities
Attend all scheduled appointments.
Take medication only as prescribed.
Follow injection instructions provided by the clinic.
Report adverse reactions promptly.
Notify the clinic of any pregnancy or significant medical changes.
Maintain recommended dietary and exercise modifications.
Keep medications stored according to provided instructions.
Understand that individual weight-loss results cannot be guaranteed.
Missed Appointments
Patients who miss scheduled visits may experience delays in medication
dispensing.
Failure to attend required follow-up appointments may result in temporary
suspension or discontinuation from the program at the provider's discretion.
Medication Dispensing
Have completed all required documentation.
Have been evaluated and approved by a provider .
Remain medically appropriate candidates.
Are current with required follow-up visits.
Have satisfied applicable program fees.
Program Goals
Safe medical weight management.
Routine clinical monitoring.
Early identification of medication side effects.
Patient education and lifestyle modification.
Improved long-term health outcomes.
Consistent follow-up and accountability.
Provider Discretion
Participation in the program remains at the discretion of the treating provider .
Medication may be withheld, adjusted, or discontinued at any time based on
medical necessity, safety concerns, treatment response, or noncompliance with
program requirements.
GLP-1 Patient Consent & Treatment Agreement
GLP-1 Weight Management Program
Patient Consent & Treatment Agreement
Purpose of Treatment
You are being evaluated for participation in the clinic’s GLP-1 Weight
Management Program. This program may include medications such as
semaglutide, tirzepatide, or other GLP-1/GIP-based therapies as determined
appropriate by your healthcare provider .
The goal of treatment is to support medically supervised weight management
through medication therapy combined with appropriate nutrition, physical
activity, and lifestyle modifications.
Medical Evaluation
I understand that prior to starting therapy, I must complete a medical evaluation
Medical history
Current medications
Weight history
Health conditions
Potential risks and contraindications
Treatment goals
The provider will determine whether GLP-1 therapy is medically appropriate for
me.
Understanding of Treatment
Weight-loss results vary between individuals.
Medication effectiveness cannot be guaranteed.
Treatment requires ongoing monitoring and follow-up.
Medication dosing may be adjusted based on my response and provider
assessment.
Treatment may be discontinued if it is determined to no longer be
medically appropriate.
Potential Risks & Side Effects
I understand that GLP-1 medications may have potential risks and side effects,
• Nausea
• Vomiting
• Diarrhea
• Constipation
Abdominal discomfort
Decreased appetite
Injection site reactions
Other potential adverse effects discussed with my provider
I agree to notify the clinic of any concerning symptoms or changes in my health
status.
Patient Responsibilities
Attend required appointments and follow-up visits.☐
Provide accurate medical history and medication information.☐
Take medication only as directed by my provider .☐
Follow storage and handling instructions provided by the clinic.☐
Notify the clinic of medication side effects or changes in my health.☐
Participate in recommended nutrition and lifestyle modifications.☐
Attend monthly monitoring appointments and scheduled provider follow-ups.☐
Follow-Up Requirements
Monthly visits are required for monitoring, including vital signs, weight
assessment, medication review, and medication dispensing.
Provider follow-up appointments are required approximately every three
months to evaluate treatment effectiveness, progress, safety, and continued
need for therapy.
Failure to attend required appointments may result in delayed medication
dispensing or discontinuation from the program.
Pregnancy and Medical Changes
I agree to notify the clinic immediately if I become pregnant, plan to become
pregnant, or experience significant medical changes.
Consent to Treatment
I acknowledge that my provider has discussed the risks, benefits, alternatives,
and expectations of GLP-1 therapy. I have had the opportunity to ask questions
and understand the information provided.
I voluntarily consent to participate in the GLP-1 Weight Management Program.
Tirzepatide Price Sheet Proposal
Tirzepatide Weight Management Program
Pricing
Medication: Tirzepatide (Lyophilized Powder)
Administration: Subcutaneous Injection
Frequency: Once Weekly
Starting Dose: 2.5 mg weekly (titrate based on clinical response and provider
protocol)
Tirzepatide 30 mg Vial
Medication Details
Vial Strength: 30 mg
Reconstitution: Add 3 mL bacteriostatic water
Final Concentration: 10 mg/mL
Vial Volume: 3 mL
Starting Dose: 2.5 mg weekly
Approximate Doses Per Vial: 12 weeks
Medication Cost
Cost Per Vial: $165
Box Requirement: 5 vials
Box Cost: $825
Cost Breakdown
Cost per 2.5 mg dose: ~$13.75
Approximate medication cost per month: ~$55
Suggested Patient Pricing
Option Patient
Price
Monthly $300 month
Option Patient
Price
Program
3-Month Package
6-Month Package
$850
$1,700
12-Month
Package $3,200
Tirzepatide 40 mg Vial
Medication Details
Vial Strength: 40 mg
Reconstitution: Add 2 mL bacteriostatic water
Final Concentration: 20 mg/mL
Vial Volume: 3 mL
Starting Dose: 2.5 mg weekly
Approximate Doses Per Vial: 16 weeks
Medication Cost
Cost Per Vial: $210
Box Requirement: 5 vials
Box Cost: $1,050
Cost Breakdown
Cost per 2.5 mg dose: ~$13.13
Approximate medication cost per month: ~$53
Suggested Patient Pricing
Option Patient
Price
Monthly $300 month
Option Patient
Price
Program
3-Month Package
6-Month Package
$850
$1,700
12-Month
Package $3,200
Tirzepatide 60 mg Vial
Medication Details
Vial Strength: 60 mg
Reconstitution: Add 2.4 mL bacteriostatic water
Final Concentration: 25 mg/mL
Vial Volume: 3 mL
Starting Dose: 2.5 mg weekly
Approximate Doses Per Vial: 24 weeks
Medication Cost
Cost Per Vial: $300
Box Requirement: 5 vials
Box Cost: $1,500
Cost Breakdown
Cost per 2.5 mg dose: ~$12.50
Approximate medication cost per month: ~$50
Suggested Patient Pricing
Option Patient
Price
Monthly Program $375/month
3-Month Package $1,050
6-Month Package $2,025
12-Month
Package $3,900
Tirzepatide 100 mg Vial
Medication Details
Vial Strength: 100 mg
Reconstitution: Add 4 mL bacteriostatic water
Final Concentration: 25 mg/mL
Vial Volume: 10 mL
Starting Dose: 2.5 mg weekly
Approximate Doses Per Vial: 40 weeks
Medication Cost
Cost Per Vial: $450
Box Requirement: 5 vials
Box Cost: $2,250
Cost Breakdown
Cost per 2.5 mg dose: ~$11.25
Approximate medication cost per month: ~$45
Suggested Patient Pricing
Option Patient Price
Monthly
Program
$375/
month
3-Month Package $1,050
6-Month Package $2,025
Recommended Clinic Pricing Model (Simplified for Patients)
Instead of charging based on vial size, many clinics simplify pricing into
Tirzepatide Weight Management Program
Program Includes Price
Initial Consultation Medical evaluation, baseline measurements,
medication education $100
Starter Program Medication + provider monitoring + dosing
adjustments $299/month
Maintenance
Program Medication management + ongoing follow-up $399/month
Higher Dose
Management
Increased dosing support + medication
adjustments $499/month
3-Month Package Medication + follow-ups $899–$1,200
6-Month Package Medication + ongoing management $1,700–
$2,400
Suggested Internal Profit Example
30 mg Vial
Medication cost: $165
Sell monthly program: $299/month
Starting dose supply lasts approximately 12 weeks
Revenue potential: ~$897
Gross medication margin: ~$732 before provider/admin costs
60 mg Vial
Medication cost: $300
Sell monthly program: $399/month
Starting dose supply lasts approximately 24 weeks
Revenue potential: ~$2,394
Gross medication margin: ~$2,094 before provider/admin costs
100 mg Vial
Medication cost: $450
Sell monthly program: $499/month
Starting dose supply lasts approximately 40 weeks
Revenue potential: ~$4,990
Gross medication margin: ~$4,540 before provider/admin costs
Important Operational Note
As patients titrate upward, medication usage increases and vial longevity
decreases. Pricing should be based on dose tiers and patient management, not
solely vial size.
Dose Tier Monthly
Price
Starter Dose (2.5 mg–5 mg weekly) $299/month
Maintenance Dose (7.5 mg–10 mg weekly) $399/month
Higher Dose Management (12.5 mg–15 mg
weekly) $499/month
After Pricing Changes
Tirzepatide 30 mg Vial
Medication Details
Vial strength: 30 mg
Concentration: 10 mg/mL
Cost: $165/vial
Cost per mg: $5.50/mg
Dose Calculation
2.5 mg weekly × 12 weeks = 30 mg
✅ Approximate doses per vial: 12 weeks
Cost Breakdown
2.5 mg × $5.50 = $13.75
$13.75 × 4 doses = $55/month
✅ Correct
Profit Example
$300 × 3 months = $900
$165
$900 - $165 = $735
✅ Your previous $732 estimate was essentially correct.
Tirzepatide 40 mg Vial
Medication Details
Vial strength: 40 mg
Concentration: 20 mg/mL
Cost: $210/vial
Dose Calculation
40 mg ÷ 2.5 mg = 16 doses
✅ Approximate vial duration: 16 weeks
Cost Breakdown
$210 ÷ 16 = $13.13
$13.13 × 4 = $52.50/month
~$53/month
✅ Correct
Profit Example
$900
$210
$690
Tirzepatide 60 mg Vial
Medication Details
Vial strength: 60 mg
Concentration: 25 mg/mL
Cost: $300
Dose Calculation
60 mg ÷ 2.5 mg = 24 doses
24 weeks
Cost Breakdown
$300 ÷ 24 = $12.50
$12.50 × 4 = $50/month
✅ Correct
Profit Example
$375 × 12 = $4,500
$300
$4,200
However, because the vial only provides ~6 months of medication at the
starting dose, this example overstates profit unless additional vials are required
as doses increase.
Revenue: $2,250
Medication: $300
Gross medication margin: $1,950
Tirzepatide 100 mg Vial
Medication Details
Vial strength: 100 mg
Concentration: 25 mg/mL
Cost: $450
Dose Calculation
100 mg ÷ 2.5 mg = 40 doses
40 weeks (~10 months)
Cost Breakdown
$450 ÷ 40 = $11.25
$11.25 × 4 = $45/month
✅ Correct
Profit Example
$3,750
$450
$3,300
$499/month × 10 months = $4,990
Margin $4,540
Math was correct, but the pricing was inconsistent with your new $375/month
model.
Corrected Patient Pricing Model
Dose Tier Monthly
Price
Starter Dose (2.5 mg–5 mg weekly) $300/month
Maintenance Dose (7.5 mg–10 mg weekly) $300/month
Higher Dose Management (12.5 mg–15 mg
weekly) $375/month
$300/month for 2.5–10 mg
$375/month for 12.5–15 mg
Recommended Internal Profit Summary
Vial Cost Starting Dose
Duration
Monthly
Price
Approx Gross Medication
Margin
30 mg $165 3 months $300/mo ~$735
40 mg $210 4 months $300/mo ~$990
60 mg $300 6 months $375/mo ~$1,950
100
mg $450 10 months $375/mo ~$3,300
Program Price
Initial Consultation $100
Tirzepatide 2.5 mg–10 mg Program $300/
month
Tirzepatide 12.5 mg–15 mg Program $375/
month
Required Provider Follow-Up Every 3
Months $45
Tirzepatide Weight Management Cash Program Pricing
Tirzepatide Weight Management Cash
Program Pricing
Medication: Tirzepatide (Lyophilized Powder)
Administration: Subcutaneous Injection
Frequency: Once Weekly
Starting Dose: 2.5 mg weekly (titrate based on clinical response and provider protocol)
Program Includes
Provider evaluation and weight-loss assessment
Personalized treatment plan
Medication education
Injection training
Medication dose adjustments based on clinical response
Monthly weight and vital sign checks with clinic staff
Side effect monitoring
Ongoing medication management
Initial Consultation
New Patient Weight Management Evaluation
Price: $100
Medical history review
Weight-loss goals assessment
BMI/body composition evaluation
Medication eligibility screening
Baseline measurements
Individualized treatment plan
Medication education
Laboratory testing may be ordered separately if medically indicated and will be billed by the
performing laboratory.
Monthly Tirzepatide Membership Options
Program Dosing Range Monthly Price
Tirzepatide Weight Management Program 2.5 mg–10 mg weekly $300/month
Tirzepatide Higher Dose Program 12.5 mg–15 mg weekly $375/month
Included Services
Weekly medication supply based on your prescribed dose
Injection training
Medication education
Medication dose adjustments as medically appropriate
Monthly weight and vital sign checks with clinic staff
Ongoing provider oversight and medication management
Provider Follow-Up Requirement
To ensure your treatment remains safe and effective, all patients are required to have an in-
office provider follow-up visit every 3 months.
Provider Follow-Up Visit: $45
Progress evaluation
Weight-loss assessment
Medication effectiveness review
Side effect evaluation
Dose adjustment, when medically indicated
Continued treatment planning
Prepaid Cash Packages
3-Month Starter Package
$850
Initial provider evaluation
Three months of medication management
Weekly medication supply based on prescribed dose
Monthly staff weight and vital sign checks
Medication education
Injection training
Medication adjustments as medically indicated
6-Month Weight Management Package
$1,700
Initial provider evaluation
Six months of medication management
Medication supply based on prescribed dose
Monthly staff weight and vital sign checks
Medication education
Injection training
Medication adjustments as medically indicated
12-Month Maintenance Package
$3,200
Initial provider evaluation
Twelve months of medication management
Medication supply based on prescribed dose
Monthly staff weight and vital sign checks
Medication education
Injection training
Medication adjustments as medically indicated
Long-term provider oversight
Simplified Patient Menu (Front Desk Version)
Medical Weight Loss Program
New Patient Evaluation
$100
Monthly Membership Options
⭐ Tirzepatide Weight Management Program
2.5 mg–10 mg weekly
$300/month
⭐ Higher Dose Tirzepatide Program
12.5 mg–15 mg weekly
$375/month
Required Provider Follow-Up: Every 3 months — $45 per visit
Tirzepatide Dose Adjustment Protocol
THE NEIGHBORHOOD CLINIC | CLINICAL PROTOCOL
Tirzepatide Dose Adjustment Protocol | Controlled copy - verify current version before use
Tirzepatide Dose Adjustment Protocol
Adult Medical Weight Management Program | Staff-guided titration under a prescriber-
approved treatment plan
Effective
Date ________________ Approved By ________________
Review Date ________________ Version 1.0
Applies To Adult weight-management
patients Owner Clinical Leadership
Clinical authority requirement
Dose changes may be implemented only when supported by an active prescription or written,
prescriber-approved titration order. Front-desk personnel may schedule and document
communications but may not assess tolerance, authorize a dose change, calculate a dose, or provide
clinical instructions.
1. Purpose
To provide a consistent and safe process for initiating and adjusting once-weekly tirzepatide in
adult patients enrolled in the clinic’s medical weight-management program. The protocol is
intended to reduce dosing errors, prevent escalation during clinically significant adverse effects,
and ensure timely provider oversight.
Scope and Core Rules
All patients begin at 2.5 mg subcutaneously once weekly and remain at that dose for a full 4
weeks.
Dose increases occur only in 2.5 mg increments and only after at least 4 weeks on the current
dose.
A separate provider visit is not required for the planned increases from 2.5 mg to 5 mg or from
5 mg to 7.5 mg when every eligibility and safety requirement in this protocol is met and a
prescriber-approved titration order is active.
A provider visit and a new or confirmed provider order are required before each increase to
10 mg, 12.5 mg, or 15 mg.
Patients are evaluated by a provider at least every 3 months, and sooner whenever clinical
concerns arise.
No staff member may convert milligrams to syringe units without using the exact, pharmacy-
labeled concentration and the clinic’s separately approved dose-conversion process.
Concentrations may differ between products.
THE NEIGHBORHOOD CLINIC | CLINICAL PROTOCOL
Tirzepatide Dose Adjustment Protocol | Controlled copy - verify current version before use
3. Standard Titration Pathway
Stage Weekly
Dose Minimum Time Decision Rule Provider Visit
Required?
Initiation 2.5 mg 4 weeks Remain at 2.5 mg for all four
weekly doses. Do not
accelerate.
No separate visit if
initial evaluation and
order are complete.
First increase 5 mg At least 4 weeks May advance after four 2.5 mg
doses if the patient passes the
tolerance and safety screen.
No separate visit
under the active
titration order.
Conditional
increase
7.5 mg At least 4 weeks at 5
mg
May advance only when the
weight-response rule and
safety screen below are
satisfied.
No separate visit
under the active
titration order.
Higher dose 10 mg At least 4 weeks at
7.5 mg
Provider evaluates response,
tolerability, risks, and
continued indication.
Yes - provider visit and
order required.
Higher dose 12.5 mg At least 4 weeks at
10 mg
Provider-directed only. Yes - provider visit and
order required.
Maximum
dose
15 mg At least 4 weeks at
12.5 mg
Provider-directed only. Do not
exceed 15 mg once weekly.
Yes - provider visit and
order required.
4. Five-Milligram Weight-Response Rule
At the end of the first 4 weeks on 5 mg, compare the current weight with the weight recorded when
5 mg began. Use a consistent scale and similar conditions whenever possible.
Change over 4
weeks Dose action Required follow-up
No weight loss or
weight gain
May increase to 7.5 mg if the
patient is tolerating 5 mg and
passes the complete safety
screen.
Document weights, tolerance screen, current
order, and staff member implementing the
change.
1 to <5 lb loss Continue 5 mg for another 4
weeks; reassess response before
considering 7.5 mg.
Escalate sooner only if specifically ordered by
the provider.
5-10 lb loss Continue 5 mg for an additional
4 weeks before considering 7.5
mg.
Document that the patient is responding and
remains on the lowest effective dose.
>10 lb loss Continue 5 mg and route to the
provider before any escalation.
Assess hydration, intake, symptoms, and
whether the rate of loss is clinically
appropriate.
Important
Weight change is not the only titration criterion. Do not increase the dose solely because weight loss
is absent. Tolerance, hydration, nutrition, glucose-lowering medications, new symptoms,
comorbidities, and the prescriber-approved plan must also be reviewed.
THE NEIGHBORHOOD CLINIC | CLINICAL PROTOCOL
Tirzepatide Dose Adjustment Protocol | Controlled copy - verify current version before use
Tolerance and Safety Screen Before Any Increase
An authorized clinical staff member must confirm and document all applicable items before
The patient completed at least 4 weekly doses at the current dose without an interruption that
requires provider review.
Current weight and date are documented, along with weight change since the current dose
began.
No persistent or severe nausea, vomiting, diarrhea, constipation, abdominal pain, or inability
to maintain food and fluid intake.
No symptoms concerning for pancreatitis, gallbladder disease, acute kidney
injury/dehydration, severe hypoglycemia, or serious hypersensitivity.
No known pregnancy or attempt to become pregnant; any pregnancy concern is routed to the
provider immediately.
No new personal or family history of medullary thyroid carcinoma, MEN 2, or previous serious
hypersensitivity to tirzepatide.
Medication list has been reviewed for insulin or sulfonylurea therapy and any hypoglycemia
plan required by the provider.
The patient is not using another tirzepatide-containing product or another GLP-1 receptor
agonist unless explicitly reconciled and directed by the prescriber.
The exact product, concentration, prescribed dose in milligrams, and administration volume
are verified against the pharmacy label and active order.
Hold Titration and Contact the Provider
Do not increase the dose. Hold further dosing when clinically appropriate under the existing order
Moderate, persistent, or worsening gastrointestinal symptoms; repeated vomiting; inability to
maintain hydration; dizziness, reduced urination, or suspected dehydration.
Severe or persistent abdominal pain, especially pain radiating to the back, with or without
vomiting.
Right-upper-quadrant pain, fever, jaundice, or other symptoms concerning for gallbladder
disease.
Symptomatic or recurrent hypoglycemia, especially when insulin or a sulfonylurea is also
prescribed.
Pregnancy, suspected pregnancy, serious allergic reaction, hospitalization, new major illness,
or any new contraindication.
A dosing error, uncertain concentration, missed doses that disrupt the titration sequence, or
use of a product that cannot be verified.
More than 10 lb of weight loss in 4 weeks, concerning nutritional intake, excessive weakness,
or any clinician concern about the rate of loss.
THE NEIGHBORHOOD CLINIC | CLINICAL PROTOCOL
Tirzepatide Dose Adjustment Protocol | Controlled copy - verify current version before use
Urgent evaluation
Symptoms of a serious allergic reaction, severe hypoglycemia, severe dehydration, or severe
persistent abdominal pain require immediate clinical assessment. Direct the patient to emergency
care when warranted by symptoms and clinic triage policy.
7. Three-Month Provider Follow-Up
Patients must be evaluated by a provider at least every 3 months. The provider visit should
Weight trend, percentage of baseline weight change, waist or body-composition measures
when used, and progress toward treatment goals.
Medication adherence, appetite response, nutritional intake, physical activity, hydration,
adverse effects, and quality-of-life impact.
Vital signs and clinically indicated laboratory monitoring based on history, comorbidities, and
concurrent medications.
Review of contraindications, pregnancy status when applicable, hypoglycemia risk, and
symptoms of pancreatitis or gallbladder disease.
Decision to continue, decrease, hold, discontinue, or advance therapy. A provider visit is
mandatory before increases to 10 mg, 12.5 mg, and 15 mg.
8. Documentation Requirements
Current dose, dates of the four most recent doses, adherence, and any missed doses.
Starting and current weight for the dose interval, total weight change, and the scale/source
used.
Tolerance and safety-screen responses, adverse effects, hydration/intake concerns, and
medication reconciliation.
Decision made, clinical staff member completing the screen, prescriber-approved order used,
and date the patient was notified.
Exact dose in milligrams. If a vial/syringe is used, also document the labeled concentration and
administration volume; do not chart “units” alone.
Next follow-up date and whether a provider visit is required before the next possible increase.
9. Missed Dose Guidance
If a weekly dose is missed, the FDA-approved instructions allow administration as soon as possible
within 4 days (96 hours). If more than 4 days have passed, skip the missed dose and resume on the
next regularly scheduled day. If multiple doses are missed or tolerance after interruption is
uncertain, contact the provider before restarting or escalating.
THE NEIGHBORHOOD CLINIC | CLINICAL PROTOCOL
Tirzepatide Dose Adjustment Protocol | Controlled copy - verify current version before use
References and Governance
This internal protocol must be reviewed and approved by the clinic’s prescribing leadership and
updated when product labeling, clinic operations, or applicable law changes. It does not replace
individualized clinical judgment, a valid prescription, the pharmacy label, or the manufacturer’s
instructions for use.
Zepbound (tirzepatide) U.S. Prescribing Information, Eli Lilly and Company:
https://pi.lilly.com/us/zepbound-uspi.pdf
FDA-approved Zepbound labeling:
https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/217806s037lbl.pdf
FDA concerns regarding unapproved/compounded GLP-1 drugs and dosing:
https://www.fda.gov/drugs/drug-alerts-and-statements/fdas-concerns-unapproved-glp-1-
drugs-used-weight-loss
Approval
_________________________________ Version: ________________
GLP-1 Weight Management - Financial Agreement
This form is image-based. Please use the printable source copy maintained by The Neighborhood Clinic.
GLP-1 Weight Management - Patient Agreement
This form is image-based. Please use the printable source copy maintained by The Neighborhood Clinic.
Tirzepatide Medication Bag / Patient Handout
This form is image-based. Please use the printable source copy maintained by The Neighborhood Clinic.
Fall Risk Self Assessment
Fall Risk Self-Assessment
Select "Yes" or "No" for each statement.
I have fallen in the past year.
☐ Yes
☐ No
I use or have been advised to use a cane or walker to get around safely.
☐ Yes
☐ No
Sometimes I feel unsteady when I am walking.
☐ Yes
☐ No
I steady myself by holding onto furniture when walking at home.
☐ Yes
☐ No
I am worried about falling.
☐ Yes
☐ No
I need to push with my hands to stand up from a chair.
☐ Yes
☐ No
I have some trouble stepping up onto a curb.
☐ Yes
☐ No
I often have to rush to the toilet.
☐ Yes
☐ No
I have lost some feeling in my feet.
☐ Yes
☐ No
I take medicine that sometimes makes me feel light-headed or more tired than usual.
☐ Yes
☐ No
I take medicine to help me sleep or improve my mood.
☐ Yes
☐ No
I often feel sad or depressed.
☐ Yes
☐ No
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Alcohol Use Disorders Identification Test AUDIT
Alcohol Use Disorders Identification Test (AUDIT)
Select the answer that best fits your alcohol use.
How often do you have a drink containing alcohol?
☐ Never
Monthly or less
2-3 times a month
4 or more times a week
How many drinks containing alcohol do you have on a typical day when drinking?
1-2
3-4
5-6
7-9
10 or more
How often do you have 6 or more drinks on one occasion?
☐ Never
Less than monthly
☐ Monthly
☐ Weekly
Daily/almost daily
How often in the last year were you unable to stop drinking once you had started?
☐ Never
Less than monthly
☐ Monthly
☐ Weekly
Daily/almost daily
How often in the last year did drinking cause you to fail to do what was normally expected?
☐ Never
Less than monthly
☐ Monthly
☐ Weekly
Daily/almost daily
How often in the last year did you need a first drink in the morning after a heavy drinking session?
☐ Never
Less than monthly
☐ Monthly
☐ Weekly
Daily/almost daily
How often in the last year did you feel guilt or remorse after drinking?
☐ Never
Less than monthly
☐ Monthly
☐ Weekly
Daily/almost daily
How often in the last year were you unable to remember what happened the night before because of drinking?
☐ Never
Less than monthly
☐ Monthly
☐ Weekly
Daily/almost daily
Have you or someone else been injured as a result of your drinking?
☐ No
Yes, not in last year
Yes, during last year
Has anyone expressed concern about your drinking or suggested you cut down?
☐ No
Yes, not in last year
Yes, during last year
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Ask Suicide Screening Questions ASQ
Ask Suicide-Screening Questions (ASQ)
Select a response for each question.
In the past few weeks, have you wished you were dead?
☐ Yes
☐ No
In the past few weeks, have you felt that you or your family would be better off if you were dead?
☐ Yes
☐ No
In the past week, have you been having thoughts about killing yourself?
☐ Yes
☐ No
Have you ever tried to kill yourself?
☐ Yes
☐ No
If yes, how? __________________________________________________________
If yes, when? _________________________________________________________
Are you having thoughts of killing yourself right now?
☐ Yes
☐ No
If yes, please describe: _________________________________________________
CLINICAL SAFETY NOTE: Any current suicidal thoughts require immediate clinical review and the clinic's suicide-safety workflow.
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Borderline Symptom List BSL 23
Borderline Symptom List (BSL-23)
Rate how much you suffered from each problem during the last week.
It was hard for me to concentrate.
Not at all
A little
☐ Rather
☐ Much
Very strong
I felt helpless.
Not at all
A little
☐ Rather
☐ Much
Very strong
I was absent-minded and unable to remember what I was actually doing.
Not at all
A little
☐ Rather
☐ Much
Very strong
I felt disgust.
Not at all
A little
☐ Rather
☐ Much
Very strong
I thought of hurting myself.
Not at all
A little
☐ Rather
☐ Much
Very strong
I didn't trust other people.
Not at all
A little
☐ Rather
☐ Much
Very strong
I didn't believe in my right to live.
Not at all
A little
☐ Rather
☐ Much
Very strong
I was lonely.
Not at all
A little
☐ Rather
☐ Much
Very strong
I experienced stressful inner tension.
Not at all
A little
☐ Rather
☐ Much
Very strong
I had images that I was very much afraid of.
Not at all
A little
☐ Rather
☐ Much
Very strong
I hated myself.
Not at all
A little
☐ Rather
☐ Much
Very strong
I wanted to punish myself.
Not at all
A little
☐ Rather
☐ Much
Very strong
I suffered from shame.
Not at all
A little
☐ Rather
☐ Much
Very strong
My mood rapidly cycled in terms of anxiety, anger, and depression.
Not at all
A little
☐ Rather
☐ Much
Very strong
I suffered from voices and noises from inside and/or outside my head.
Not at all
A little
☐ Rather
☐ Much
Very strong
Criticism had a devastating effect on me.
Not at all
A little
☐ Rather
☐ Much
Very strong
I felt vulnerable.
Not at all
A little
☐ Rather
☐ Much
Very strong
The idea of death had a certain fascination for me.
Not at all
A little
☐ Rather
☐ Much
Very strong
Everything seemed senseless to me.
Not at all
A little
☐ Rather
☐ Much
Very strong
I was afraid of losing control.
Not at all
A little
☐ Rather
☐ Much
Very strong
I felt disgusted by myself.
Not at all
A little
☐ Rather
☐ Much
Very strong
I felt as if I was far away from myself.
Not at all
A little
☐ Rather
☐ Much
Very strong
I felt worthless.
Not at all
A little
☐ Rather
☐ Much
Very strong
Overall personal state last week (0%-100%): _______%
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
CAGE Alcohol Abuse Screening Tool
CAGE Alcohol Abuse Screening Tool
Answer based on your whole life.
Have you ever felt that you ought to cut down on your drinking?
☐ Yes
☐ No
Have people annoyed you by criticizing your drinking or drug use?
☐ Yes
☐ No
Have you ever felt bad or guilty about your drinking?
☐ Yes
☐ No
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?
☐ Yes
☐ No
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
CAGE AID Substance Abuse Screening Tool
CAGE-AID Substance Abuse Screening Tool
Include alcohol, illegal drugs, and prescription drugs used other than as prescribed.
Have you ever felt that you ought to cut down on your drinking or drug use?
☐ Yes
☐ No
Have people annoyed you by criticizing your drinking or drug use?
☐ Yes
☐ No
Have you ever felt bad or guilty about your drinking or drug use?
☐ Yes
☐ No
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a
hangover?
☐ Yes
☐ No
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Drug Abuse Screening Test DAST 10
Drug Abuse Screening Test (DAST-10)
These questions refer to drug use in the past 12 months and exclude alcoholic beverages.
Have you used drugs other than those required for medical reasons?
☐ Yes
☐ No
Do you use more than one drug at a time?
☐ Yes
☐ No
Are you always able to stop using drugs when you want to?
☐ Yes
☐ No
Have you had "blackouts" or "flashbacks" as a result of drug use?
☐ Yes
☐ No
Do you ever feel bad or guilty about your drug use?
☐ Yes
☐ No
Does your spouse (or parents) ever complain about your involvement with drugs?
☐ Yes
☐ No
Have you neglected your family because of drug use?
☐ Yes
☐ No
Have you engaged in illegal activities to obtain drugs?
☐ Yes
☐ No
Have you experienced withdrawal symptoms when you stopped taking drugs?
☐ Yes
☐ No
Have you had medical problems as a result of drug use?
☐ Yes
☐ No
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Generalized Anxiety Disorder Assessment GAD 7
Generalized Anxiety Disorder Assessment (GAD-7)
Over the last two weeks, how often have you been bothered by the following problems?
Feeling nervous or on edge
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying
Not at all
Several days
More than half the days
Nearly every day
Worrying too much about different things
Not at all
Several days
More than half the days
Nearly every day
Trouble relaxing
Not at all
Several days
More than half the days
Nearly every day
Being so restless that it is hard to sit still
Not at all
Several days
More than half the days
Nearly every day
Becoming easily annoyed or irritable
Not at all
Several days
More than half the days
Nearly every day
Feeling afraid as if something awful might happen
Not at all
Several days
More than half the days
Nearly every day
How difficult have these problems made work, home responsibilities, or getting along with others?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Hamilton Anxiety Rating Scale HAM A
Hamilton Anxiety Rating Scale (HAM-A)
Rate each of the 14 symptom domains.
Anxious mood
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
2. Tension
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
3. Fears
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
4. Insomnia
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
Intellectual / concentration and memory
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
Depressed mood
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
Somatic - muscular
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
Somatic - sensory
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
Cardiovascular symptoms
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
Respiratory symptoms
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
Gastrointestinal symptoms
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
Genitourinary symptoms
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
Autonomic symptoms
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
Behavior during interview/assessment
Not present
☐ Mild
☐ Moderate
☐ Severe
Very severe
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Mood Feelings Questionnaire MFQ Long Version Adult Self Report
Mood & Feelings Questionnaire (MFQ): Long Version,
Adult Self-Report
Answer how you have been feeling or acting in the past two weeks.
I felt miserable or unhappy
Not true
☐ Sometimes
☐ True
I didn't enjoy anything at all
Not true
☐ Sometimes
☐ True
I was less hungry than usual
Not true
☐ Sometimes
☐ True
I ate more than usual
Not true
☐ Sometimes
☐ True
I felt so tired I just sat around and did nothing
Not true
☐ Sometimes
☐ True
I was moving and walking more slowly than usual
Not true
☐ Sometimes
☐ True
I was very restless
Not true
☐ Sometimes
☐ True
I felt I was no good anymore
Not true
☐ Sometimes
☐ True
I blamed myself for things that weren't my fault
Not true
☐ Sometimes
☐ True
It was hard for me to make up my mind
Not true
☐ Sometimes
☐ True
I felt grumpy and cross with other people
Not true
☐ Sometimes
☐ True
I felt like talking less than usual
Not true
☐ Sometimes
☐ True
I was talking more slowly than usual
Not true
☐ Sometimes
☐ True
I cried a lot
Not true
☐ Sometimes
☐ True
I thought there was nothing good for me in the future
Not true
☐ Sometimes
☐ True
I thought that life wasn't worth living
Not true
☐ Sometimes
☐ True
I thought about death or dying
Not true
☐ Sometimes
☐ True
I thought my family would be better off without me
Not true
☐ Sometimes
☐ True
I thought about killing myself
Not true
☐ Sometimes
☐ True
I didn't want to see my friends
Not true
☐ Sometimes
☐ True
I found it hard to think properly or concentrate
Not true
☐ Sometimes
☐ True
I thought bad things would happen to me
Not true
☐ Sometimes
☐ True
I hated myself
Not true
☐ Sometimes
☐ True
I was a bad person
Not true
☐ Sometimes
☐ True
I thought I looked ugly
Not true
☐ Sometimes
☐ True
I worried about aches and pains
Not true
☐ Sometimes
☐ True
I felt lonely
Not true
☐ Sometimes
☐ True
I thought nobody really loved me
Not true
☐ Sometimes
☐ True
I didn't have any fun in any of my activities
Not true
☐ Sometimes
☐ True
I did everything wrong
Not true
☐ Sometimes
☐ True
I thought I could never be as good as other people
Not true
☐ Sometimes
☐ True
I didn't sleep as well as I usually sleep
Not true
☐ Sometimes
☐ True
I slept a lot more than usual
Not true
☐ Sometimes
☐ True
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Mood Feelings Questionnaire MFQ Long Version Child Self Report
Mood & Feelings Questionnaire (MFQ): Long Version,
Child Self-Report
Answer how you have been feeling or acting in the past two weeks.
I felt miserable or unhappy
Not true
☐ Sometimes
☐ True
I didn't enjoy anything at all
Not true
☐ Sometimes
☐ True
I was less hungry than usual
Not true
☐ Sometimes
☐ True
I ate more than usual
Not true
☐ Sometimes
☐ True
I felt so tired I just sat around and did nothing
Not true
☐ Sometimes
☐ True
I was moving and walking more slowly than usual
Not true
☐ Sometimes
☐ True
I was very restless
Not true
☐ Sometimes
☐ True
I felt I was no good anymore
Not true
☐ Sometimes
☐ True
I blamed myself for things that weren't my fault
Not true
☐ Sometimes
☐ True
It was hard for me to make up my mind
Not true
☐ Sometimes
☐ True
I felt grumpy and cross with my parents
Not true
☐ Sometimes
☐ True
I felt like talking less than usual
Not true
☐ Sometimes
☐ True
I was talking more slowly than usual
Not true
☐ Sometimes
☐ True
I cried a lot
Not true
☐ Sometimes
☐ True
I thought there was nothing good for me in the future
Not true
☐ Sometimes
☐ True
I thought that life wasn't worth living
Not true
☐ Sometimes
☐ True
I thought about death or dying
Not true
☐ Sometimes
☐ True
I thought my family would be better off without me
Not true
☐ Sometimes
☐ True
I thought about killing myself
Not true
☐ Sometimes
☐ True
I didn't want to see my friends
Not true
☐ Sometimes
☐ True
I found it hard to think properly or concentrate
Not true
☐ Sometimes
☐ True
I thought bad things would happen to me
Not true
☐ Sometimes
☐ True
I hated myself
Not true
☐ Sometimes
☐ True
I was a bad person
Not true
☐ Sometimes
☐ True
I thought I looked ugly
Not true
☐ Sometimes
☐ True
I worried about aches and pains
Not true
☐ Sometimes
☐ True
I felt lonely
Not true
☐ Sometimes
☐ True
I thought nobody really loved me
Not true
☐ Sometimes
☐ True
I didn't have any fun in school
Not true
☐ Sometimes
☐ True
I did everything wrong
Not true
☐ Sometimes
☐ True
I thought I could never be as good as other kids
Not true
☐ Sometimes
☐ True
I didn't sleep as well as I usually sleep
Not true
☐ Sometimes
☐ True
I slept a lot more than usual
Not true
☐ Sometimes
☐ True
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Mood Feelings Questionnaire MFQ Long Version Parent Guardian Report
Mood & Feelings Questionnaire (MFQ): Long Version,
Parent-Guardian Report
Answer how your child might have been feeling or acting in the past two weeks.
S/he felt miserable or unhappy
Not true
☐ Sometimes
☐ True
S/he didn't enjoy anything at all
Not true
☐ Sometimes
☐ True
S/he was less hungry than usual
Not true
☐ Sometimes
☐ True
S/he ate more than usual
Not true
☐ Sometimes
☐ True
S/he felt so tired s/he just sat around and did nothing
Not true
☐ Sometimes
☐ True
S/he was moving and walking more slowly than usual
Not true
☐ Sometimes
☐ True
S/he was very restless
Not true
☐ Sometimes
☐ True
S/he felt s/he was no good anymore
Not true
☐ Sometimes
☐ True
S/he blamed him/herself for things that weren't his/her fault
Not true
☐ Sometimes
☐ True
It was hard for him/her to make up his/her mind
Not true
☐ Sometimes
☐ True
S/he felt grumpy and cross with his/her parents
Not true
☐ Sometimes
☐ True
S/he felt like talking less than usual
Not true
☐ Sometimes
☐ True
S/he was talking more slowly than usual
Not true
☐ Sometimes
☐ True
S/he cried a lot
Not true
☐ Sometimes
☐ True
S/he thought there was nothing good for him/her in the future
Not true
☐ Sometimes
☐ True
S/he thought life wasn't worth living
Not true
☐ Sometimes
☐ True
S/he thought about death or dying
Not true
☐ Sometimes
☐ True
S/he thought the family would be better off without him/her
Not true
☐ Sometimes
☐ True
S/he didn't want to see friends
Not true
☐ Sometimes
☐ True
S/he found it hard to think properly or concentrate
Not true
☐ Sometimes
☐ True
S/he thought bad things would happen
Not true
☐ Sometimes
☐ True
S/he hated him/herself
Not true
☐ Sometimes
☐ True
S/he felt s/he was a bad person
Not true
☐ Sometimes
☐ True
S/he thought s/he looked ugly
Not true
☐ Sometimes
☐ True
S/he worried about aches and pains
Not true
☐ Sometimes
☐ True
S/he felt lonely
Not true
☐ Sometimes
☐ True
S/he thought nobody really loved him/her
Not true
☐ Sometimes
☐ True
S/he didn't have any fun at school
Not true
☐ Sometimes
☐ True
S/he thought s/he could never be as good as other kids
Not true
☐ Sometimes
☐ True
S/he felt s/he did everything wrong
Not true
☐ Sometimes
☐ True
S/he didn't sleep as well as usual
Not true
☐ Sometimes
☐ True
S/he slept a lot more than usual
Not true
☐ Sometimes
☐ True
S/he wasn't as happy as usual even when praised or rewarded
Not true
☐ Sometimes
☐ True
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
MFQ Short Version Adult Self Report
MFQ: Short Version, Adult Self-Report
Answer for the past two weeks.
I felt miserable or unhappy
Not true
☐ Sometimes
☐ True
I didn't enjoy anything at all
Not true
☐ Sometimes
☐ True
I felt so tired I just sat around and did nothing
Not true
☐ Sometimes
☐ True
I was very restless
Not true
☐ Sometimes
☐ True
I felt I was no good anymore
Not true
☐ Sometimes
☐ True
I cried a lot
Not true
☐ Sometimes
☐ True
I found it hard to think properly or concentrate
Not true
☐ Sometimes
☐ True
I hated myself
Not true
☐ Sometimes
☐ True
I was a bad person
Not true
☐ Sometimes
☐ True
I felt lonely
Not true
☐ Sometimes
☐ True
I thought nobody really loved me
Not true
☐ Sometimes
☐ True
I thought I could never be as good as other people
Not true
☐ Sometimes
☐ True
I did everything wrong
Not true
☐ Sometimes
☐ True
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
MFQ Short Version Child Self Report
MFQ: Short Version, Child Self-Report
Answer for the past two weeks.
I felt miserable or unhappy
Not true
☐ Sometimes
☐ True
I didn't enjoy anything at all
Not true
☐ Sometimes
☐ True
I felt so tired I just sat around and did nothing
Not true
☐ Sometimes
☐ True
I was very restless
Not true
☐ Sometimes
☐ True
I felt I was no good anymore
Not true
☐ Sometimes
☐ True
I cried a lot
Not true
☐ Sometimes
☐ True
I found it hard to think properly or concentrate
Not true
☐ Sometimes
☐ True
I hated myself
Not true
☐ Sometimes
☐ True
I was a bad person
Not true
☐ Sometimes
☐ True
I felt lonely
Not true
☐ Sometimes
☐ True
I thought nobody really loved me
Not true
☐ Sometimes
☐ True
I thought I could never be as good as other kids
Not true
☐ Sometimes
☐ True
I did everything wrong
Not true
☐ Sometimes
☐ True
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
MFQ Short Version Parent Guardian Report
MFQ: Short Version, Parent-Guardian Report
Answer for the child's past two weeks.
S/he felt miserable or unhappy
Not true
☐ Sometimes
☐ True
S/he didn't enjoy anything at all
Not true
☐ Sometimes
☐ True
S/he felt so tired s/he just sat around and did nothing
Not true
☐ Sometimes
☐ True
S/he was very restless
Not true
☐ Sometimes
☐ True
S/he felt s/he was no good anymore
Not true
☐ Sometimes
☐ True
S/he cried a lot
Not true
☐ Sometimes
☐ True
S/he found it hard to think properly or concentrate
Not true
☐ Sometimes
☐ True
S/he hated him/herself
Not true
☐ Sometimes
☐ True
S/he felt s/he was a bad person
Not true
☐ Sometimes
☐ True
S/he felt lonely
Not true
☐ Sometimes
☐ True
S/he thought nobody really loved him/her
Not true
☐ Sometimes
☐ True
S/he thought s/he could never be as good as other kids
Not true
☐ Sometimes
☐ True
S/he felt s/he did everything wrong
Not true
☐ Sometimes
☐ True
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Mood Disorder Questionnaire MDQ
Mood Disorder Questionnaire (MDQ)
Has there ever been a period when you were not your usual self and...
You felt so good or hyper that others thought you were not your normal self or you got into trouble?
☐ Yes
☐ No
You were so irritable that you shouted at people or started fights/arguments?
☐ Yes
☐ No
You felt much more self-confident than usual?
☐ Yes
☐ No
You got much less sleep than usual and didn't really miss it?
☐ Yes
☐ No
You were much more talkative or spoke faster than usual?
☐ Yes
☐ No
Thoughts raced through your head or you couldn't slow your mind down?
☐ Yes
☐ No
You were so easily distracted that you had trouble concentrating or staying on track?
☐ Yes
☐ No
You had much more energy than usual?
☐ Yes
☐ No
You were much more active or did many more things than usual?
☐ Yes
☐ No
You were much more social or outgoing than usual?
☐ Yes
☐ No
You were much more interested in sex than usual?
☐ Yes
☐ No
You did things that were unusual, excessive, foolish, or risky?
☐ Yes
☐ No
Spending money got you or your family in trouble?
☐ Yes
☐ No
If YES to more than one above, have several ever happened during the same period?
☐ Yes
☐ No
How much of a problem did any of these cause?
No problem
Minor problem
Moderate problem
Serious problem
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Opioid Risk Tool ORT Female Version
Opioid Risk Tool (ORT): Female Version
Answer Yes or No depending on whether each item applies.
Age between 16-45 years?
☐ Yes
☐ No
Family history of alcohol abuse?
☐ Yes
☐ No
Family history of illegal drug use?
☐ Yes
☐ No
Family history of prescription drug abuse?
☐ Yes
☐ No
Personal history of alcohol abuse?
☐ Yes
☐ No
Personal history of illegal drug use?
☐ Yes
☐ No
Personal history of prescription drug abuse?
☐ Yes
☐ No
History of preadolescent sexual abuse?
☐ Yes
☐ No
Personal history of ADD/ADHD, OCD, bipolar disorder, or schizophrenia?
☐ Yes
☐ No
Personal history of depression?
☐ Yes
☐ No
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Opioid Risk Tool ORT Male Version
Opioid Risk Tool (ORT): Male Version
Answer Yes or No depending on whether each item applies.
Age between 16-45 years?
☐ Yes
☐ No
Family history of alcohol abuse?
☐ Yes
☐ No
Family history of illegal drug use?
☐ Yes
☐ No
Family history of prescription drug abuse?
☐ Yes
☐ No
Personal history of alcohol abuse?
☐ Yes
☐ No
Personal history of illegal drug use?
☐ Yes
☐ No
Personal history of prescription drug abuse?
☐ Yes
☐ No
History of preadolescent sexual abuse?
☐ Yes
☐ No
Personal history of ADD/ADHD, OCD, bipolar disorder, or schizophrenia?
☐ Yes
☐ No
Personal history of depression?
☐ Yes
☐ No
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
PEG Pain Screening Tool
PEG: Pain Screening Tool
Rate each item from 0-10.
Pain on average in the past week: 0 1 2 3 4 5 6 7 8 9 10
Pain interference with enjoyment of life in the past week: 0 1 2 3 4 5 6 7 8 9 10
Pain interference with general activity in the past week: 0 1 2 3 4 5 6 7 8 9 10
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
PHQ 9 Modified for Adolescents PHQ A
PHQ-9 Modified for Adolescents (PHQ-A)
Over the past two weeks, select the best response.
Feeling down, depressed, irritable, or hopeless?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Little interest or pleasure in doing things?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Trouble falling asleep, staying asleep, or sleeping too much?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Poor appetite, weight loss, or overeating?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Feeling tired or having little energy?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Feeling bad about yourself or feeling that you are a failure or let yourself/family down?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Trouble concentrating on school work, reading, or watching TV?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Moving/speaking so slowly others noticed, or being much more fidgety/restless than usual?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Thoughts that you would be better off dead, or of hurting yourself in some way?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
How difficult have these problems made daily functioning?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
In the past year have you felt depressed or sad most days?
☐ Yes
☐ No
In the past month have you had serious thoughts about ending your life?
☐ Yes
☐ No
Have you ever tried to kill yourself or made a suicide attempt?
☐ Yes
☐ No
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
PHQ A Combined with ASQ
PHQ-A Combined with ASQ
Complete the PHQ-A followed by the ASQ.
Feeling down, depressed, irritable, or hopeless?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Little interest or pleasure in doing things?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Trouble falling asleep, staying asleep, or sleeping too much?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Poor appetite, weight loss, or overeating?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Feeling tired or having little energy?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Feeling bad about yourself or feeling that you are a failure or let yourself/family down?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Trouble concentrating on school work, reading, or watching TV?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Moving/speaking so slowly others noticed, or being much more fidgety/restless than usual?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
Thoughts that you would be better off dead, or of hurting yourself in some way?
Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
How difficult have these problems made daily functioning?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
In the past year have you felt depressed or sad most days?
☐ Yes
☐ No
In the past month have you had serious thoughts about ending your life?
☐ Yes
☐ No
Have you ever tried to kill yourself or made a suicide attempt?
☐ Yes
☐ No
SECTION 3 - ASQ
In the past few weeks, have you wished you were dead?
☐ Yes
☐ No
In the past few weeks, have you felt you or your family would be better off if you were dead?
☐ Yes
☐ No
In the past week, have you been having thoughts about killing yourself?
☐ Yes
☐ No
Have you ever tried to kill yourself?
☐ Yes
☐ No
If yes, how? __________________________
If yes, when? __________________________
Are you having thoughts of killing yourself right now?
☐ Yes
☐ No
If yes, describe: ______________________
CLINICAL SAFETY NOTE: Any current suicidal thoughts require immediate clinical review and the clinic's suicide-safety workflow.
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Pain Self Efficacy Questionnaire PSEQ
Pain Self-Efficacy Questionnaire (PSEQ)
I can enjoy things, despite the pain 0 1 2 3 4 5 6 7 8 9 10
I can do most household chores, despite the pain 0 1 2 3 4 5 6 7 8 9 10
I can socialize with friends/family as often as I used to, despite the pain 0 1 2 3 4 5 6 7 8 9 10
I can cope with my pain in most situations 0 1 2 3 4 5 6 7 8 9 10
I can do some form of work, despite the pain 0 1 2 3 4 5 6 7 8 9 10
I can still do many things I enjoy, despite the pain 0 1 2 3 4 5 6 7 8 9 10
I can cope with my pain without medication 0 1 2 3 4 5 6 7 8 9 10
I can still accomplish most of my goals in life, despite the pain 0 1 2 3 4 5 6 7 8 9 10
I can live a normal lifestyle, despite the pain 0 1 2 3 4 5 6 7 8 9 10
I can gradually become more active, despite the pain 0 1 2 3 4 5 6 7 8 9 10
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Panic Disorder Severity Scale PDSS
Panic Disorder Severity Scale (PDSS)
Rate the past week using the 0-4 severity scale.
Number/frequency of panic and limited-symptom attacks during the past week
0 - None
1 - Mild
2 - Moderate
3 - Severe
4 - Extreme
Distress caused by panic/limited-symptom attacks
0 - None
1 - Mild
2 - Moderate
3 - Severe
4 - Extreme
Worry or anxiety about the next panic attack
0 - None
1 - Mild
2 - Moderate
3 - Severe
4 - Extreme
Fear/avoidance of places or situations because of panic
0 - None
1 - Mild
2 - Moderate
3 - Severe
4 - Extreme
Fear/avoidance of activities that cause panic-like physical sensations
0 - None
1 - Mild
2 - Moderate
3 - Severe
4 - Extreme
Interference with work/home responsibilities
0 - None
1 - Mild
2 - Moderate
3 - Severe
4 - Extreme
Interference with social life
0 - None
1 - Mild
2 - Moderate
3 - Severe
4 - Extreme
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Patient Health Questionnaire PHQ 2
Patient Health Questionnaire (PHQ-2)
Over the past two weeks, how often have you been bothered by these problems?
Little interest or pleasure in doing things
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
Not at all
Several days
More than half the days
Nearly every day
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Patient Health Questionnaire PHQ 9
Patient Health Questionnaire (PHQ-9)
Over the past two weeks, how often have you been bothered by these problems?
Little interest or pleasure in doing things
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
Not at all
Several days
More than half the days
Nearly every day
Trouble falling/staying asleep or sleeping too much
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself or that you are a failure or have let yourself/family down
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things
Not at all
Several days
More than half the days
Nearly every day
Moving/speaking slowly or being unusually fidgety/restless
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
Not at all
Several days
More than half the days
Nearly every day
How difficult have these problems made daily functioning?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Patient Screening Form
Patient Screening Form
Answer the following illness/COVID-19 screening questions.
Fever or felt feverish in the last 14-21 days?
☐ Yes
☐ No
Shortness of breath or other difficulty breathing?
☐ Yes
☐ No
Cough?
☐ Yes
☐ No
Flu-like symptoms such as GI upset, headache, or fatigue?
☐ Yes
☐ No
Recent loss of taste or smell?
☐ Yes
☐ No
Contact with confirmed COVID-19 patients?
☐ Yes
☐ No
Age over 60?
☐ Yes
☐ No
Heart, lung, kidney disease, diabetes, or autoimmune disorder?
☐ Yes
☐ No
Travel in the past 14 days to regions affected by COVID-19?
☐ Yes
☐ No
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Pediatric Symptom Checklist 17 PSC 17
Pediatric Symptom Checklist-17 (PSC-17)
Indicate how often your child has had each experience over the past two weeks.
Feel sad.
☐ Never
☐ Sometimes
☐ Often
Feel hopeless.
☐ Never
☐ Sometimes
☐ Often
Feel down on him/herself.
☐ Never
☐ Sometimes
☐ Often
Worry a lot.
☐ Never
☐ Sometimes
☐ Often
Seem to be having less fun.
☐ Never
☐ Sometimes
☐ Often
Fidget / unable to sit still.
☐ Never
☐ Sometimes
☐ Often
Daydream too much.
☐ Never
☐ Sometimes
☐ Often
Distract easily.
☐ Never
☐ Sometimes
☐ Often
Have trouble concentrating.
☐ Never
☐ Sometimes
☐ Often
Act as if driven by a motor.
☐ Never
☐ Sometimes
☐ Often
Fight with other children.
☐ Never
☐ Sometimes
☐ Often
Not listen to rules.
☐ Never
☐ Sometimes
☐ Often
Not understand other people's feelings.
☐ Never
☐ Sometimes
☐ Often
Tease others.
☐ Never
☐ Sometimes
☐ Often
Blame others for his/her troubles.
☐ Never
☐ Sometimes
☐ Often
Refuse to share.
☐ Never
☐ Sometimes
☐ Often
Take things that do not belong to him/her.
☐ Never
☐ Sometimes
☐ Often
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Posttraumatic Stress Disorder Checklist for DSM 5 PCL 5
Posttraumatic Stress Disorder Checklist for DSM-5
(PCL-5)
Rate how much each problem bothered you IN THE LAST MONTH.
Repeated, disturbing, unwanted memories of the stressful experience?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Repeated, disturbing dreams of the stressful experience?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Suddenly feeling or acting as if the stressful experience were happening again?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Feeling very upset when reminded of the stressful experience?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Strong physical reactions when reminded of the stressful experience?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Avoiding memories, thoughts, or feelings related to the experience?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Avoiding external reminders of the experience?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Trouble remembering important parts of the experience?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Strong negative beliefs about yourself, others, or the world?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Blaming yourself or someone else for the experience or what happened after it?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Strong negative feelings such as fear, horror, anger, guilt, or shame?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Loss of interest in activities you used to enjoy?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Feeling distant or cut off from other people?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Trouble experiencing positive feelings?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Irritable behavior, angry outbursts, or acting aggressively?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Taking too many risks or doing things that could cause harm?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Being superalert/watchful/on guard?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Feeling jumpy or easily startled?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Difficulty concentrating?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
Trouble falling or staying asleep?
Not at all
A little bit
☐ Moderately
Quite a bit
☐ Extremely
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Rapid Opioid Dependence Screen RODS
Rapid Opioid Dependence Screen (RODS)
First list any opioids ever taken. If none, answer No to questions 2-8.
Opioids ever taken (select/list all that apply): ______________________________________________
Did you ever need to use more opioids to get the same high as when you first started?
☐ Yes
☐ No
Did the idea of missing a dose ever make you anxious or worried?
☐ Yes
☐ No
In the morning, did you ever use opioids to keep from feeling 'dope sick' or feel 'dope sick'?
☐ Yes
☐ No
Did you worry about your use of opioids?
☐ Yes
☐ No
Did you find it difficult to stop or not use opioids?
☐ Yes
☐ No
Did you spend a lot of time/energy finding opioids or recovering from feeling high?
☐ Yes
☐ No
Did you miss important things because of opioids?
☐ Yes
☐ No
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Vanderbilt Assessment Follow Up Parent Guardian Informant
Vanderbilt Assessment Follow Up: Parent-Guardian
Informant
Consider what is appropriate for the child's age. Think about behaviors in the past 6 months.
At time of evaluation, child was:
On medication
Not on medication
Not sure
Does not pay attention to details or makes careless mistakes
☐ Never
☐ Occasionally
☐ Often
Very often
Has difficulty keeping attention to what needs to be done
☐ Never
☐ Occasionally
☐ Often
Very often
Does not seem to listen when spoken to directly
☐ Never
☐ Occasionally
☐ Often
Very often
Does not follow through when given directions and fails to finish activities
☐ Never
☐ Occasionally
☐ Often
Very often
Has difficulty organizing tasks and activities
☐ Never
☐ Occasionally
☐ Often
Very often
Avoids/dislikes tasks requiring ongoing mental effort
☐ Never
☐ Occasionally
☐ Often
Very often
Loses things necessary for tasks/activities
☐ Never
☐ Occasionally
☐ Often
Very often
Is easily distracted by noises or other stimuli
☐ Never
☐ Occasionally
☐ Often
Very often
Is forgetful in daily activities
☐ Never
☐ Occasionally
☐ Often
Very often
Fidgets with hands/feet or squirms in seat
☐ Never
☐ Occasionally
☐ Often
Very often
Leaves seat when remaining seated is expected
☐ Never
☐ Occasionally
☐ Often
Very often
Runs about or climbs too much when remaining seated is expected
☐ Never
☐ Occasionally
☐ Often
Very often
Has difficulty playing or beginning quiet play activities
☐ Never
☐ Occasionally
☐ Often
Very often
Is "on the go" or acts as if "driven by a motor"
☐ Never
☐ Occasionally
☐ Often
Very often
Talks too much
☐ Never
☐ Occasionally
☐ Often
Very often
Blurts out answers before questions are completed
☐ Never
☐ Occasionally
☐ Often
Very often
Has difficulty waiting turn
☐ Never
☐ Occasionally
☐ Often
Very often
Interrupts or intrudes on others' conversations/activities
☐ Never
☐ Occasionally
☐ Often
Very often
Overall school performance
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
21. Reading
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
22. Writing
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
23. Mathematics
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
Relationship with parents
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
Relationship with siblings
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
Relationship with peers
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
Participation in organized activities
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
28. Headache
☐ None
☐ Mild
☐ Moderate
☐ Severe
29. Stomachache
☐ None
☐ Mild
☐ Moderate
☐ Severe
Change of appetite
☐ None
☐ Mild
☐ Moderate
☐ Severe
Trouble sleeping / irritability later in day
☐ None
☐ Mild
☐ Moderate
☐ Severe
Socially withdrawn
☐ None
☐ Mild
☐ Moderate
☐ Severe
Extreme sadness or unusual crying
☐ None
☐ Mild
☐ Moderate
☐ Severe
Dull/tired/listless behavior
☐ None
☐ Mild
☐ Moderate
☐ Severe
Tremors/feeling shaky
☐ None
☐ Mild
☐ Moderate
☐ Severe
Repetitive movements/tics/twitching/eye blinking
☐ None
☐ Mild
☐ Moderate
☐ Severe
Skin/finger picking, nail-biting, lip/cheek chewing
☐ None
☐ Mild
☐ Moderate
☐ Severe
Sees or hears things that aren't there
☐ None
☐ Mild
☐ Moderate
☐ Severe
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Vanderbilt Assessment Scale Parent Guardian Informant
Vanderbilt Assessment Scale: Parent-Guardian
Informant
Consider what is appropriate for the child's age. Think about behaviors in the past 6 months.
At time of evaluation, child was:
On medication
Not on medication
Not sure
Does not pay attention to details or makes careless mistakes
☐ Never
☐ Occasionally
☐ Often
Very often
Has difficulty keeping attention to what needs to be done
☐ Never
☐ Occasionally
☐ Often
Very often
Does not seem to listen when spoken to directly
☐ Never
☐ Occasionally
☐ Often
Very often
Does not follow through when given directions and fails to finish activities
☐ Never
☐ Occasionally
☐ Often
Very often
Has difficulty organizing tasks and activities
☐ Never
☐ Occasionally
☐ Often
Very often
Avoids/dislikes tasks requiring ongoing mental effort
☐ Never
☐ Occasionally
☐ Often
Very often
Loses things necessary for tasks/activities
☐ Never
☐ Occasionally
☐ Often
Very often
Is easily distracted by noises or other stimuli
☐ Never
☐ Occasionally
☐ Often
Very often
Is forgetful in daily activities
☐ Never
☐ Occasionally
☐ Often
Very often
Fidgets with hands/feet or squirms in seat
☐ Never
☐ Occasionally
☐ Often
Very often
Leaves seat when remaining seated is expected
☐ Never
☐ Occasionally
☐ Often
Very often
Runs about or climbs too much when remaining seated is expected
☐ Never
☐ Occasionally
☐ Often
Very often
Has difficulty playing or beginning quiet play activities
☐ Never
☐ Occasionally
☐ Often
Very often
Is "on the go" or acts as if "driven by a motor"
☐ Never
☐ Occasionally
☐ Often
Very often
Talks too much
☐ Never
☐ Occasionally
☐ Often
Very often
Blurts out answers before questions are completed
☐ Never
☐ Occasionally
☐ Often
Very often
Has difficulty waiting turn
☐ Never
☐ Occasionally
☐ Often
Very often
Interrupts or intrudes on others' conversations/activities
☐ Never
☐ Occasionally
☐ Often
Very often
Argues with adults
☐ Never
☐ Occasionally
☐ Often
Very often
Loses temper
☐ Never
☐ Occasionally
☐ Often
Very often
Actively defies/refuses adults' requests or rules
☐ Never
☐ Occasionally
☐ Often
Very often
Deliberately annoys people
☐ Never
☐ Occasionally
☐ Often
Very often
Blames others for mistakes/misbehavior
☐ Never
☐ Occasionally
☐ Often
Very often
Is touchy/easily annoyed
☐ Never
☐ Occasionally
☐ Often
Very often
Is angry or resentful
☐ Never
☐ Occasionally
☐ Often
Very often
Is spiteful/wants to get even
☐ Never
☐ Occasionally
☐ Often
Very often
Bullies/threatens/intimidates others
☐ Never
☐ Occasionally
☐ Often
Very often
Starts physical fights
☐ Never
☐ Occasionally
☐ Often
Very often
Lies to get out of trouble/avoid obligations
☐ Never
☐ Occasionally
☐ Often
Very often
Is truant from school without permission
☐ Never
☐ Occasionally
☐ Often
Very often
Is physically cruel to people
☐ Never
☐ Occasionally
☐ Often
Very often
Has stolen things of value
☐ Never
☐ Occasionally
☐ Often
Very often
Deliberately destroys others' property
☐ Never
☐ Occasionally
☐ Often
Very often
Has used a weapon that can cause serious harm
☐ Never
☐ Occasionally
☐ Often
Very often
Is physically cruel to animals
☐ Never
☐ Occasionally
☐ Often
Very often
Has deliberately set fires to cause damage
☐ Never
☐ Occasionally
☐ Often
Very often
Has broken into someone else's home/business/car
☐ Never
☐ Occasionally
☐ Often
Very often
Has stayed out at night without permission
☐ Never
☐ Occasionally
☐ Often
Very often
Has run away from home overnight
☐ Never
☐ Occasionally
☐ Often
Very often
Has forced someone into sexual activity
☐ Never
☐ Occasionally
☐ Often
Very often
Is fearful/anxious/worried
☐ Never
☐ Occasionally
☐ Often
Very often
Is afraid to try new things for fear of mistakes
☐ Never
☐ Occasionally
☐ Often
Very often
Feels worthless/inferior
☐ Never
☐ Occasionally
☐ Often
Very often
Blames self for problems/feels guilty
☐ Never
☐ Occasionally
☐ Often
Very often
Feels lonely/unwanted/unloved
☐ Never
☐ Occasionally
☐ Often
Very often
Is sad/unhappy/depressed
☐ Never
☐ Occasionally
☐ Often
Very often
Is self-conscious/easily embarrassed
☐ Never
☐ Occasionally
☐ Often
Very often
Overall school performance
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
50. Reading
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
51. Writing
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
52. Mathematics
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
Relationship with parents
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
Relationship with siblings
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
Relationship with peers
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
Participation in organized activities
☐ N/A
☐ Excellent
Above average
☐ Average
Somewhat of a problem
☐ Problematic
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Patient Information and Health Summary
Patient Information and Health Summary
Complete the demographic and health-summary fields.
First name*: __________________ Middle: ______________ Last name*: __________________
Date of birth*: ______________ Email: ______________________________
Preferred phone: __________________ Cell phone: __________________
Preferred language: __________________ Sex: ☐ Male ☐ Female ☐ Unspecified
Address 1: ______________________________________________
Address 2: ______________________________________________
City: __________________ State: ______ Zip: __________
Do you drink alcohol? __________ If yes, how much/how often? __________________________
Do you smoke? __________ If yes, packs/day: __________________
Do you exercise? __________ Type/frequency: __________________________________________
Do you consume caffeine? __________ Type/frequency: ____________________________________
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Prescriptions
Prescriptions
Complete all medication, allergy, and pharmacy information.
First name*: ______________________________ Last name*: ______________________________
Date of birth*: __________________
Currently taking prescription/non-prescription medications or supplements?* __________________
Medication, dosage, frequency: _________________________________________________________
_____________________________________________________________________________________
Medication allergies?* __________________
If yes, medication(s) and reaction(s): _________________________________________________
Preferred pharmacy name and address*: __________________________________________________
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Counseling New Patient Form
Counseling New Patient Form
Complete all applicable intake fields. Enter N/A where appropriate.
First name*: __________________ Middle: ______________ Last name*: __________________
DOB*: __________ Preferred name: ______________ Email*: __________________________
Preferred phone*: __________________ Cell*: __________________
__________________
Preferred language: __________________ Preferred communication: __________________ Sex: __________
Primary insurance subscriber/payer/policy/group: ______________________________________
Relationship status / marriage-divorce-widowed-cohabitation details: _____________________________
Previous therapy? ______ Currently in therapy elsewhere? ______ If yes, where/when: __________________
Current medications, dosage, frequency: _______________________________________________________
Previous inpatient psychiatric / drug-alcohol rehab / hospitalizations: _____________________________
Reasons for attending therapy / current stressors: ______________________________________________
Current coping (0%-100%): _______%
Religious/church affiliation and attendance, if any: ____________________________________________
Violence in home / spouse violence / children witnessed violence - describe if applicable: _____________
Current alcohol use, last use, amount, years used, frequency: ____________________________________
Current substance/prescription misuse, frequency: ______________________________________________
Family history of mental illness, suicide, depression, substance use, eating disorders/addictions: ________
How many sessions do you think you may need to get back on track? _______________________________
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Columbia Suicide Severity Rating Scale C SSRS
Columbia Suicide Severity Rating Scale (C-SSRS)
Complete the screening questions in sequence. If Question 2 is Yes, continue through ideation questions.
First name: __________________ Last name: __________________ DOB: __________
Cell phone: __________________ Preferred phone: __________________
Have you wished you were dead or wished you could go to sleep and not wake up?
☐ Yes
☐ No
Have you actually had any thoughts of killing yourself?
☐ Yes
☐ No
Have you been thinking of ways that you might do this?
☐ Yes
☐ No
Have you had these thoughts and had some intention of acting on them?
☐ Yes
☐ No
Have you worked out details of how to kill yourself and do you intend to carry out this plan?
☐ Yes
☐ No
Have you done anything, started to do anything, or prepared to do anything to end your life?
☐ Yes
☐ No
CLINICAL SAFETY NOTE: Any current suicidal intent, plan, or preparatory behavior requires immediate clinical review and the clinic's
suicide-safety workflow.
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Consent to Treat a Minor Counseling
Consent to Treat a Minor - Counseling
Complete by the legally authorized parent/guardian.
Minor first name: __________________ Last name: __________________ DOB: __________
______________________________
I certify that I have legal authority to consent to treatment for this minor.
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Medical History Form
Medical History Form
Complete all applicable medical and family-history fields.
First name: __________________ Last name: __________________ DOB: __________
If cancer, diabetes, and/or heart condition, specify type: _________________________________________
If other, elaborate: _________________________________________________________________________
Family members with these conditions? ______ Who/type: ________________________________________
Other chronic conditions that run in the family: _________________________________________________
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Release of Information
Release of Information
Complete all applicable authorization fields.
First name: __________________ Last name: __________________ DOB: __________
Email: ______________________________ Cell: __________________
Sex: ☐ Male ☐ Female ☐ Unspecified
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Credit Card on File Authorization Consent
Credit Card on File Authorization & Consent
Select whether you authorize The Neighborhood Clinic to securely store a credit/debit card on file.
First name: __________________ Last name: __________________ DOB: __________
Card on file authorization: ☐ YES ☐ NO
If YES, I understand my card may be used for copayments, coinsurance, deductibles, balances after insurance,
self-pay services, and applicable missed-appointment fees.
If NO, I understand I remain financially responsible for balances and may be required to pay at time of service or
upon receipt of a statement.
I understand card information will be stored securely; I may revoke authorization in writing; revocation does not
eliminate prior charges; declining does not affect my ability to receive treatment.
CLINICAL SAFETY NOTE: This form authorizes storage/charging only as described by clinic policy; staff should not write full card numbers
on this paper form.
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Medical History Preventive Screenings Form
Medical History & Preventive Screenings Form
Complete medical, family, surgical, and screening history.
First name: __________________ Last name: __________________ DOB: __________
If cancer, diabetes, and/or heart condition, specify type: _________________________________________
If other, elaborate: _________________________________________________________________________
Family members with these conditions? ______ Who/type: ________________________________________
Other chronic conditions that run in the family: _________________________________________________
Annual Physical - last completed date/location: _________________________________________________
Prostate Cancer Screening - last completed date/lab location: ___________________________________
This questionnaire/form is a starting point and is not a substitute for a full medical evaluation. Follow current TNC clinical, documentation,
privacy, and escalation policies.
Notice of Privacy Practices HIPAA
Notice of Privacy Practices (HIPAA)
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.
The Neighborhood Clinic is committed to protecting the privacy of your health information. This Notice describes how we
may use and disclose your medical information and explains your rights regarding your health information.
How We May Use and Disclose Your Health Information
Treatment
We may use your health information to provide medical treatment or services. For example, your provider may share
information with nurses, medical assistants, pharmacies, specialists, or other healthcare professionals involved in your
care.
Payment
We may use and disclose your information to bill and receive payment for services provided to you. For example, we
may send information to your insurance company to process claims and obtain payment.
Healthcare Operations
Quality improvement
Staff training
Business management
Compliance activities
Licensing and accreditation
Other Permitted Uses and Disclosures
Public health reporting
Health oversight activities
Law enforcement requests
Workers' compensation claims
Judicial or administrative proceedings
Preventing a serious threat to health or safety
Appointment Reminders and Communication
We may contact you to remind you about appointments, treatment options, or healthcare services that may benefit you.
This may include phone calls, voicemail, text messages, or patient portal messages.
Your Rights Regarding Your Health Information
Right to inspect and obtain copies of your medical records
Right to request amendments if you believe information is incorrect or incomplete
Right to request restrictions on how your health information is used or disclosed
Right to request confidential communications in a specific way or location
Right to an accounting of certain disclosures
Right to a paper copy of this Notice
Our Responsibilities
Maintain the privacy of your health information
Provide you with this Notice of Privacy Practices
Follow the terms of this Notice
Notify you if a breach occurs that may compromise the privacy or security of your information
We reserve the right to revise this Notice at any time. The revised Notice will apply to all information we maintain and will
be available in our office and on our website.
Questions or Complaints
If you believe your privacy rights have been violated, you may file a complaint with The Neighborhood Clinic. You may
also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. You will not be
penalized for filing a complaint.
HIPAA Acknowledgement of Receipt of Notice of Privacy Practices
By signing below, you acknowledge that you have received or been offered the opportunity to review The Neighborhood
Clinic's Notice of Privacy Practices. Your signature does not mean that you agree with the Notice; it means that you
received or had the opportunity to review it.
Consentimiento para Extracci n de Muestras de Laboratorio
Consentimiento para Extracción de Muestras de
Laboratorio
Yo, el/la abajo firmante, doy mi consentimiento voluntario para la recolección de muestras de laboratorio (incluyendo
sangre, orina u otros tipos de muestras) según lo ordenado por mi proveedor de atención médica en The Neighborhood
Clinic.
Entiendo que este procedimiento puede implicar una venopunción (inserción de una aguja en una vena) u otros
métodos de recolección necesarios para pruebas diagnósticas.
Propósito de las Pruebas
Entiendo que el propósito de la recolección de muestras es ayudar en el diagnóstico, tratamiento y/o monitoreo de mi
condición médica.
Riesgos y Posibles Complicaciones
Dolor leve o molestia en el sitio
Moretones o sangrado
Infección (raro)
Mareo o desmayo
Autorización para Pruebas y Divulgación de Información
La realización de pruebas de laboratorio según lo ordenado por mi proveedor
La entrega de mis muestras a laboratorios contratados para su análisis
La divulgación de los resultados de mis pruebas a mi proveedor y al personal de salud correspondiente involucrado
en mi atención
Responsabilidad Financiera
Los servicios de laboratorio pueden ser facturados por separado por el laboratorio que realiza las pruebas
Soy responsable de cualquier costo no cubierto por mi seguro
Es mi responsabilidad verificar la cobertura con mi compañía de seguros
Reconocimiento del Paciente
He tenido la oportunidad de hacer preguntas sobre este procedimiento
Mis preguntas han sido respondidas a mi satisfacción
Entiendo que puedo retirar mi consentimiento en cualquier momento antes de la recolección de la muestra
Consentimiento
Al firmar a continuación, reconozco que he leído y entendido este formulario y doy mi consentimiento voluntario para la
recolección de muestras de laboratorio.
Firma del paciente/representante: ________________________________________ Fecha: ______________
Consentimiento para Comunicaci n Electr nica
Consentimiento para Comunicación Electrónica
The Neighborhood Clinic puede comunicarse con los pacientes de manera electrónica para mejorar el acceso y la
coordinación de la atención.
Las comunicaciones electrónicas pueden incluir recordatorios de citas, mensajes a través del portal del paciente,
correos electrónicos, mensajes de texto e instrucciones de seguimiento.
Tipos de Comunicación Pueden Incluir
Programación y recordatorios de citas, actualizaciones generales de salud, coordinación de la atención entre
proveedores, actualizaciones de medicamentos y recetas, información de referencias, consultas relacionadas con
facturación o seguros y respuestas a preguntas de pacientes que no sean urgentes.
Riesgos de la Comunicación Electrónica
Aunque se utilizan medidas de seguridad razonables, la comunicación electrónica puede implicar riesgos como el
acceso no autorizado.
Responsabilidades del Paciente
Proporcionar información de contacto precisa y notificar a la clínica si esta cambia.
La comunicación electrónica no debe utilizarse para emergencias. En caso de emergencia, llame al 911.
Firma del paciente/representante: ________________________________________ Fecha: ______________
Testosterone Therapy Agreement
Testosterone Therapy Agreement
Purpose of Treatment
I understand that I am being prescribed testosterone therapy for treatment of a diagnosed medical condition. The goal of
therapy is to improve symptoms associated with low testosterone levels.
Patient Responsibilities & Agreement
Medication Use - I will take testosterone only as prescribed, will not change or stop it without consulting my provider,
and understand misuse may result in discontinuation.
Controlled Substance Acknowledgment - I understand testosterone is a controlled substance under federal law; I will
not share, sell, or distribute it; lost, stolen, or damaged medication may not be replaced.
Monitoring & Follow-Up - I agree to complete required lab work, including testosterone levels, CBC, CMP, PSA if
applicable, and other provider-ordered tests; I will attend scheduled follow-up appointments.
Pharmacy & Prescriptions - I agree to use one designated pharmacy unless otherwise approved; I will request refills in
advance; early refills may not be granted.
Substance Use & Compliance - I agree to disclose all medications and supplements; drug screening may be required
at the provider's discretion; I agree not to use illicit substances while undergoing therapy.
Risks & Side Effects - Potential risks may include increased red blood cell count (polycythemia), cardiovascular risks,
sleep apnea, acne or skin reactions, fertility suppression, and mood changes. I have had the opportunity to discuss risks,
benefits, and alternatives.
Discontinuation - Therapy may be discontinued if I fail to follow this agreement, miss required labs or appointments,
there is evidence of misuse/diversion, or treatment is no longer medically appropriate.
Consent
I voluntarily consent to testosterone therapy and agree to comply with all terms outlined in this agreement.
Aviso de Pr cticas de Privacidad HIPAA Espa ol
Aviso de Prácticas de Privacidad (HIPAA) - Español
ESTE AVISO DESCRIBE CÓMO SE PUEDE USAR Y DIVULGAR SU INFORMACIÓN MÉDICA Y CÓMO USTED
PUEDE TENER ACCESO A ESTA INFORMACIÓN. POR FAVOR REVÍSELO CUIDADOSAMENTE.
The Neighborhood Clinic está comprometida a proteger la privacidad de su información de salud. Este Aviso describe
cómo podemos usar y divulgar su información médica y explica sus derechos con respecto a su información de salud.
Cómo Podemos Usar y Divulgar Su Información de Salud
Tratamiento
Podemos usar su información de salud para proporcionarle tratamiento médico o servicios. Por ejemplo, su proveedor
puede compartir información con enfermeras, asistentes médicos, farmacias, especialistas u otros profesionales de la
salud involucrados en su atención.
Pago
Podemos usar y divulgar su información para facturar y recibir pago por los servicios que se le brindan. Por ejemplo,
podemos enviar información a su compañía de seguros para procesar reclamaciones y obtener el pago.
Operaciones de Atención Médica
Mejora de la calidad
Capacitación del personal
Administración del negocio
Actividades de cumplimiento
Licencias y acreditaciones
Otros Usos y Divulgaciones Permitidos
Reportes de salud pública
Actividades de supervisión de salud
Solicitudes de las autoridades legales
Reclamaciones de compensación laboral
Procedimientos judiciales o administrativos
Prevención de una amenaza grave para la salud o la seguridad
Recordatorios de Citas y Comunicación
Podemos comunicarnos con usted para recordarle citas, opciones de tratamiento o servicios de salud que puedan
beneficiarle. Esto puede incluir llamadas telefónicas, mensajes de voz, mensajes de texto o mensajes a través del portal
del paciente.
Sus Derechos
Inspeccionar y obtener copias de sus registros médicos
Solicitar enmiendas
Solicitar restricciones
Solicitar comunicaciones confidenciales
Solicitar un registro de ciertas divulgaciones
Solicitar una copia en papel de este Aviso
Nuestras Responsabilidades
Mantener la privacidad de su información de salud
Proporcionarle este Aviso de Prácticas de Privacidad
Cumplir con los términos de este Aviso
Notificarle si ocurre una violación que pueda comprometer la privacidad o seguridad de su información
Nos reservamos el derecho de modificar este Aviso en cualquier momento. El Aviso revisado se aplicará a toda la
información que mantenemos y estará disponible en nuestra oficina y en nuestro sitio web.
Preguntas o Quejas
Si considera que sus derechos de privacidad han sido violados, puede presentar una queja ante The Neighborhood
Clinic. También puede presentar una queja ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios
Humanos de los Estados Unidos. No se le penalizará por presentar una queja.
Reconocimiento de Recepción
Al firmar a continuación, usted reconoce que ha recibido o se le ha ofrecido la oportunidad de revisar el Aviso de
Prácticas de Privacidad de The Neighborhood Clinic.
Firma del paciente/representante: ________________________________________ Fecha: ______________
Therapy Groups Disclosure Statement
Therapy Groups Disclosure Statement
Purpose of Group Therapy
Group therapy provides an opportunity for participants to receive support, learn new skills, share experiences, and work
toward personal goals in a structured therapeutic environment.
Confidentiality
The Neighborhood Clinic is committed to protecting your privacy. Information shared during group therapy sessions is
confidential and protected by applicable federal and state laws. Because group therapy involves multiple participants,
confidentiality cannot be absolutely guaranteed. Participants are expected to respect the privacy of others and agree not
to disclose information shared by fellow group members outside the group setting.
Exceptions to Confidentiality May Include
Threats of harm to self or others
Suspected abuse or neglect of a child, elder, or vulnerable adult
Court orders or other legal requirements
Medical emergencies
Situations otherwise required by law
Group Expectations
Treat all group members with respect
Maintain confidentiality of information shared during sessions
Do not record audio/video or take photographs during group sessions
Participate in a manner that promotes a safe and supportive environment
Follow clinic policies and behavioral expectations
Attendance & Financial Responsibility
I understand attendance is important to the success of group therapy. I am responsible for applicable copays,
deductibles, coinsurance, self-pay fees, or balances not covered by insurance.
Patient Rights
Ask questions about treatment
Participate voluntarily
Withdraw from group therapy at any time
Request information about alternative treatment options
Seek a second opinion
Emergency Services
Group therapy is not an emergency service. If I experience a mental health crisis or medical emergency, I will call 911,
call or text 988, or proceed to the nearest emergency department.
Consent
I acknowledge that I have read and understand this agreement. I voluntarily consent to participate in group therapy
services through The Neighborhood Clinic.
Patient Rights Responsibilities
Patient Rights & Responsibilities
Patient Responsibilities
1. Provide Accurate Information
Share complete and truthful information about medical history, medications, symptoms, and changes in health
Inform the clinic of changes in contact information or insurance coverage
Participate in Care
Ask questions when you do not understand your care or treatment plan
Follow agreed-upon treatment plans or discuss alternatives if concerns arise
Keep scheduled appointments or notify the clinic in advance if you must cancel
Respect the Clinic Environment
Treat staff, providers, and other patients with courtesy and respect
Refrain from disruptive, abusive, threatening, or violent behavior
Follow clinic rules related to safety, infection control, and conduct
4. Financial Responsibility
Understand your insurance benefits and coverage
Pay copays, deductibles, or balances as required or arrange payment plans when applicable
5. Use Services Appropriately
Use emergency services appropriately and understand after-hours and urgent care procedures
Follow clinic policies related to prescriptions, refills, and controlled substances
Patient Rights
Respectful & Nondiscriminatory Care
Receive care with dignity, respect, and courtesy at all times
Be treated without discrimination based on race, color, ethnicity, national origin, language, religion, sex, gender
identity, sexual orientation, age, disability, marital status, veteran status, or ability to pay
Privacy & Confidentiality
Have personal health information protected in accordance with HIPAA and applicable state laws
Receive care in a setting that respects privacy
Review, request copies of, or request corrections to medical records
Informed Care & Decision-Making
Receive clear explanations about diagnosis, treatment options, risks, and benefits in understandable language
Ask questions and receive answers before agreeing to treatment
Participate actively in decisions regarding care
Accept or refuse treatment to the extent permitted by law
Access to Care
Receive appropriate medical and behavioral health care regardless of insurance status or ability to pay
Request language assistance services at no cost, including interpreters
Receive reasonable accommodations for disabilities
5. Transparency
Receive information about clinic policies, fees, billing practices, and payment options
Know the identity and role of healthcare professionals involved in care
Safety & Quality
Receive care in a safe environment
Be free from abuse, neglect, harassment, or exploitation
Voice concerns about safety or quality of care without fear of retaliation
Complaints & Grievances
File a complaint or grievance regarding care or services
Receive information on how to submit concerns and expect timely follow-up
Contact appropriate regulatory agencies if concerns are not resolved
Formulario de Consentimiento para Telesalud
Formulario de Consentimiento para Telesalud
La telesalud utiliza tecnología de comunicación electrónica para permitir que los proveedores diagnostiquen, consulten,
traten, eduquen y monitoreen a los pacientes cuando el paciente y el proveedor no están físicamente juntos.
Beneficios
Mayor acceso a la atención médica y reducción del tiempo de traslado
Riesgos Potenciales
Dificultades técnicas, limitaciones de los exámenes a distancia y posibles riesgos de seguridad asociados con la
comunicación electrónica
Alternativas
Usted puede solicitar atención en persona cuando esté disponible
Confidencialidad
Los servicios de telesalud se realizan en cumplimiento con las regulaciones de privacidad de HIPAA
Usted puede retirar su consentimiento para los servicios de telesalud en cualquier momento.
Firma del paciente/representante: ________________________________________ Fecha: ______________
Consent to Treat Unaccompanied Minor
Consent to Treat Unaccompanied Minor
This form is to be completed by a parent or legal guardian on behalf of each minor and filed in the minor's chart prior to
treatment.
I authorize The Neighborhood Clinic to provide routine medical care and treatment on behalf of the minor, which may
include examination, x-ray, and filling prescriptions, from appropriate healthcare providers and clinic personnel.
I authorize release of medical information necessary to process insurance claims concerning the minor. I authorize
payment of medical benefits for care rendered and understand I am financially responsible for amounts not covered by
health insurance.
I agree that this consent is given freely and with knowledge of its purpose in order to provide medical care and treatment
for the minor.
Minor Name: ________________________________________ DOB: ______________
Informed Consent Contract for Controlled Substance Medications
Informed Consent / Contract for Controlled Substance
Medications
The following information is provided to assist you with making an informed decision regarding the use of controlled
substance medication. Please review this information and ask any questions you may have.
Controlled substance prescription medications may be used to treat conditions including moderate to severe pain,
attention disorders, anxiety, seizures, sleeping disorders, obesity, and others. When taken as directed, they can be
effective aids in management and treatment.
Potential Risks
Heart attack or stroke
Hormonal imbalance
Liver or kidney dysfunction
Abnormal thoughts or behavior
Memory loss or disturbances
• Stupor
Physical dependence
• Tolerance
Misuse or abuse
Addiction or relapse
Respiratory depression
• Overdose
• Coma
• Death
Monitoring & Appointments
I agree to appropriate laboratory testing and office exams as recommended and/or a minimum of every 3 months.
Controlled substance medications will only be filled at the time of my follow-up appointment. No refills will be called in if I
miss my appointment.
Refills & Medication Safety
Telephone refills are not allowed; pharmacy refill calls/faxes will not be authorized
I will keep medication safe and secure; lost, stolen, or damaged medication will not be replaced
I will not change dose or frequency and will take medication only as prescribed
Medication is intended only for me and I will not share it
I will not seek the same controlled substance from other prescribers, emergency departments, dentists, or others
without discussing it with my provider
Drug Monitoring
I understand I may be asked to leave a urine sample at follow-up appointments and/or complete random drug screening.
If requested, I agree to engage in therapy to learn behavioral skills and support safe medication use.
Prescription Monitoring
I understand my provider may verify controlled substance prescriptions through the applicable state prescription
monitoring program.
Pill Counts & Contact Information
I agree to come in for a pill count within 24 hours of being called and understand I must keep current contact information
on file.
Stopping Medication
I understand abrupt discontinuation of certain controlled medications may cause withdrawal symptoms. I agree to
discuss discontinuation with a provider before stopping medication.
Conduct
I agree to treat clinic staff respectfully. I understand disruptive, abusive, or threatening behavior may affect continuation
of treatment and/or the patient relationship according to clinic policy and applicable requirements.
Pregnancy
Female patients: if I plan to become pregnant or believe I am pregnant while taking these medications, I will immediately
inform my prescriber and obstetric provider.
Termination of Controlled-Substance Therapy
I understand controlled-substance therapy may be terminated if I violate this agreement, misuse/divert medication,
obtain non-authorized controlled substances, or use non-prescribed illicit drugs. I understand withdrawal risks and will
work with a provider on safe discontinuation when medically appropriate.
Acknowledgment
I certify that I received and understand this information, had my questions answered, and understand that I have the
option not to take controlled substance medication.
Behavioral Health Services Informed Consent
Behavioral Health Services Informed Consent
I voluntarily consent to receive behavioral health services through The Neighborhood Clinic. Services may include
assessments, counseling, treatment planning, behavioral health interventions, telehealth services when appropriate, and
other services deemed medically necessary by my provider.
Provider Information
My treating behavioral health provider may be any licensed clinician employed by or contracted with The Neighborhood
Clinic. Services will be provided within the scope of the provider's licensure and professional training.
Confidentiality
Information discussed during treatment is confidential and protected by federal and state privacy laws. Confidentiality
Suspected abuse or neglect of a child, elder, or vulnerable adult
Threats of harm to myself or others
Medical emergencies
Court orders or other legal requirements
Insurance billing and payment purposes
Healthcare operations as permitted by law
Insurance and Financial Responsibility
If I use insurance benefits, I authorize The Neighborhood Clinic to release information necessary to obtain payment. I am
responsible for copays, deductibles, coinsurance, non-covered services, and balances not paid by insurance.
Patient Rights
Ask questions regarding treatment
Participate in treatment decisions
Refuse treatment
Request records as permitted by law
Seek a second opinion
Discontinue treatment at any time
Emergencies
The Neighborhood Clinic does not provide emergency mental health services. If I experience a medical or mental health
emergency, I will call 911, call or text 988, or proceed to the nearest emergency department.
Consent
I have read and understand this consent form, have had the opportunity to ask questions, and voluntarily consent to
receive behavioral health services through The Neighborhood Clinic.
How to Update Your Medical Information
How to Update Your Medical Information
To help us provide you with the best care, please update your information in our patient portal powered by RXNT.
Step 1: Log Into the Patient Portal
Open your email and look for your portal invitation
Click the link and create your login if you have not already
If you already have an account, log in
Step 2: Access Your Health Information
Go to your profile or health record section
Look for Medications, Medical History, Surgical History, and Allergies
Step 3: Update Your Information
Medications - include prescriptions, over-the-counter medications, vitamins, and supplements
Medical History - current or past conditions
Surgical History - past surgeries; approximate dates are okay
Allergies - medication or food allergies and reactions
If you are unsure about something, you may enter 'unknown' or let our staff know at your visit.
Step 4: Save Your Changes
Be sure to save or submit updates before logging out
Need Help?
If you have trouble logging in or updating your information, please call our office and our team will help you.
Consentimiento para Tratamiento
Consentimiento para Tratamiento
Yo doy mi consentimiento voluntario para recibir atención y tratamiento médico por parte de los médicos, enfermeros
practicantes, asistentes médicos, enfermeras, asistentes médicos clínicos y otros profesionales de la salud de The
Neighborhood Clinic.
Este consentimiento incluye atención médica rutinaria, exámenes, procedimientos diagnósticos, pruebas de laboratorio,
medicamentos y tratamientos que mi proveedor considere necesarios o recomendables.
Alcance del Consentimiento
Realizar exámenes y evaluaciones médicas rutinarias
Ordenar y realizar pruebas diagnósticas y servicios de laboratorio
Administrar medicamentos y tratamientos según sea necesario
Proporcionar atención preventiva, aguda y crónica
Referirme a especialistas u otros proveedores cuando sea médicamente necesario
Este consentimiento se aplica a los servicios prestados durante mi visita de hoy y futuras visitas para atención médica
rutinaria, a menos que revoque este consentimiento por escrito.
Responsabilidades del Paciente
Proporcionar información médica precisa y completa
Informar sobre alergias, medicamentos o condiciones de salud
Seguir recomendaciones médicas y planes de tratamiento acordados
Hacer preguntas si no entiendo alguna parte de mi atención
Responsabilidad Financiera
Entiendo que soy responsable del pago de los servicios médicos proporcionados, incluidos copagos, coaseguros y
deducibles, según la Política de Responsabilidad Financiera de The Neighborhood Clinic.
Servicios de Telesalud (Si Aplica)
Si se proporcionan servicios de telesalud, entiendo que la atención puede brindarse mediante tecnologías de
comunicación electrónica y puede tener limitaciones en comparación con visitas en persona.
Tratamiento de Menores
Si el paciente es menor de edad, el padre, madre o tutor legal que firma autoriza el tratamiento del menor y acepta la
responsabilidad financiera aplicable.
Reconocimiento
He leído y entiendo este Consentimiento para Tratamiento. He tenido la oportunidad de hacer preguntas y todas han
sido respondidas a mi satisfacción.
Firma del paciente/representante: ________________________________________ Fecha: ______________
Acuerdo de Responsabilidad Financiera
Acuerdo de Responsabilidad Financiera
Gracias por elegir a The Neighborhood Clinic como su proveedor de atención médica. Este documento describe las
responsabilidades financieras del paciente.
Facturación de Seguro
Como cortesía, presentamos reclamaciones a su compañía de seguros. Sin embargo, la cobertura de seguro es un
contrato entre usted y su aseguradora, y usted es en última instancia responsable de todos los cargos.
Copagos, Deducibles y Coaseguro
Todos los copagos, deducibles y coaseguros deben pagarse en el momento del servicio, a menos que se hayan hecho
arreglos previos.
Servicios No Cubiertos
Si su seguro no cubre un servicio, usted es responsable del saldo.
Política de Citas Perdidas
Por favor notifique a nuestra oficina con al menos 24 horas de anticipación si necesita cancelar. Las citas perdidas
pueden resultar en un cargo que no está cubierto por el seguro.
Cheques Devueltos
Puede aplicarse un cargo por cheques devueltos.
Cobranza
Las cuentas no pagadas después de intentos razonables de cobro pueden ser enviadas a una agencia de cobranza.
Autorización para Facturar al Seguro
Autorizo a The Neighborhood Clinic a divulgar la información médica necesaria para procesar reclamaciones de seguro
y recibir el pago.
Firma del paciente/representante: ________________________________________ Fecha: ______________
Disclosure and Consent to Injection Treatment
Disclosure and Consent to Injection Treatment
The following information is provided so you can be fully informed about medications recommended for treatment. After
reviewing this form and having your questions answered, sign below to consent.
Medication / Purpose / Possible Side Effects or Risks
Kenalog - Corticosteroid for inflammation, allergies, arthritis. Possible risks: swelling, injection-site pain, dizziness, high
blood pressure, mood changes, infection risk, dimpling at injection site.
Solu-Medrol - Anti-inflammatory for allergic reactions, autoimmune issues, asthma flare. Possible risks: stomach
irritation, insomnia, mood swings, increased blood sugar, infection risk, dimpling at injection site.
Rocephin - Antibiotic for bacterial infections. Possible risks: injection-site reaction, diarrhea, rash, allergic reaction,
liver-enzyme changes.
Vitamin B12 - Treat or prevent B12 deficiency. Possible risks: mild diarrhea, itching, swelling, blood clots (rare),
dizziness, numbness, tingling.
Diphenhydramine - Antihistamine for allergic reactions. Possible risks: drowsiness, dizziness, dry mouth, confusion,
injection-site irritation.
Toradol - Non-steroidal anti-inflammatory for pain relief. Possible risks: nausea, drowsiness, dizziness, swelling, kidney
issues, gastrointestinal bleeding.
Lidocaine - Local anesthetic for numbing injection site / nerve blocks. Possible risks: redness, swelling, tingling,
lightheadedness, allergic reactions, arrhythmia.
Consent
I understand the benefits, risks, and alternatives to receiving this medication. I have had my questions answered and
agree to proceed with the injection.
Consent to Treat
Consent to Treat
I voluntarily consent to medical care and treatment by the physicians, nurse practitioners, physician assistants, nurses,
medical assistants, and other healthcare professionals of The Neighborhood Clinic.
This consent includes routine medical care, examinations, diagnostic procedures, laboratory testing, medications, and
treatment that my healthcare provider considers necessary or advisable. I understand that medicine is not an exact
science and no guarantees have been made regarding results.
Scope of Consent
Perform routine medical examinations and evaluations
Order and perform diagnostic tests and laboratory services
Administer medications and treatments as necessary
Provide preventive, acute, and chronic medical care
Refer me to specialists or other healthcare providers when medically necessary
This consent applies to services provided during my visit today and future visits for routine medical care unless I revoke
this consent in writing.
Patient Responsibilities
Provide accurate and complete medical history information
Inform my provider of allergies, medications, or health conditions
Follow medical advice and treatment plans as discussed
Ask questions if I do not understand any part of my care
Financial Responsibility
I understand that I am responsible for payment of medical services provided, including copayments, coinsurance, and
deductibles, as outlined in The Neighborhood Clinic's Financial Responsibility Policy.
Telehealth Services (If Applicable)
If telehealth services are provided, I understand healthcare may be delivered through electronic communication
technologies and may have limitations compared with in-person visits.
Consent for Treatment of Minors
If the patient is a minor, the parent or legal guardian signing below authorizes treatment of the minor and agrees to
applicable financial responsibility.
Acknowledgment
I have read and understand this Consent to Treat. I have had the opportunity to ask questions and all questions have
been answered to my satisfaction.
Telehealth Consent Form
Telehealth Consent Form
Telehealth uses electronic communication technology to allow providers to diagnose, consult, treat, educate, and
monitor patients when the patient and provider are not physically together.
Benefits
Increased access to care and reduced travel time.
Potential Risks
Technical difficulties, limitations of remote examinations, and possible security risks associated with electronic
communication.
Alternatives
You may request in-person care whenever available.
Confidentiality
Telehealth services are conducted in compliance with HIPAA privacy regulations.
You may withdraw consent for telehealth services at any time.
Financial Responsibility Agreement
Financial Responsibility Agreement
Thank you for choosing The Neighborhood Clinic as your healthcare provider. This document outlines patient financial
responsibilities.
Insurance Billing
As a courtesy, we submit claims to your insurance carrier. Insurance coverage is a contract between you and your
insurer, and you are ultimately responsible for all charges.
Copayments, Deductibles, and Coinsurance
All copays, deductibles, and coinsurance are due at the time of service unless prior arrangements are made.
Non-Covered Services
If your insurance does not cover a service, you are responsible for the balance.
Missed Appointment Policy
Please notify our office at least 24 hours in advance if you need to cancel. Missed appointments may result in a fee not
covered by insurance.
Returned Checks
A fee may apply to returned checks.
Collections
Accounts unpaid after reasonable attempts to collect may be referred to collections.
Authorization to Bill Insurance
I authorize The Neighborhood Clinic to release medical information necessary to process insurance claims and receive
payment.
Consent for AI Assisted Audio Documentation of Clinical Visits
Consent for AI-Assisted Audio Documentation of Clinical
Visits
Provider: ______________________________________________ Date of Visit: ______________
Purpose
I understand that my healthcare provider may use secure audio and/or video recording technology during my clinical visit
to assist with medical documentation. The recording may be processed by a HIPAA-compliant artificial intelligence (AI)
system to create clinical notes, visit summaries, and treatment documentation. My provider will review and approve
documentation before it becomes part of my medical record.
Recording and Use
Audio recording of my visit and, when clinically appropriate, video recording
Use of a HIPAA-compliant AI system to transcribe and summarize the visit
Inclusion of finalized documentation in my medical record for treatment, payment, healthcare operations, and other
uses permitted by law
Privacy and Security
Recordings are stored using secure, encrypted, HIPAA-compliant systems
Access is limited to authorized personnel and approved technology vendors operating under appropriate privacy
agreements
Recordings may be deleted after documentation is finalized in accordance with applicable retention policies and legal
requirements
Risks and Benefits
Benefits may include improved documentation accuracy, more complete medical records, reduced administrative
burden, and enhanced continuity of care. As with any electronic system, there is a small risk of unauthorized access
despite safeguards. AI-generated content may contain errors; all documentation is reviewed by a licensed healthcare
provider before finalization.
Patient Rights
Participation is voluntary
I may decline recording and still receive medical care
I may withdraw consent at any time before or during the recording process
I may ask questions about the recording or AI documentation process before signing
Authorization
I have read and understand this consent form, have had the opportunity to ask questions, and voluntarily consent to
recording of my clinical visit and use of AI-assisted documentation as described above.
Consent for Lab Draw
Consent for Lab Draw
I voluntarily consent to the collection of laboratory specimens, including but not limited to blood, urine, or other samples,
as ordered by my healthcare provider at The Neighborhood Clinic.
I understand this procedure may involve venipuncture or other specimen collection methods necessary for diagnostic
testing.
Purpose of Testing
The purpose of specimen collection is to assist in diagnosis, treatment, and/or monitoring of my medical condition.
Risks and Potential Complications
Mild pain or discomfort at the site
Bruising or bleeding
Infection (rare)
Dizziness or fainting
Authorization for Testing and Release of Information
Performance of laboratory testing as ordered by my provider
Release of specimens to contracted laboratories for analysis
Release of test results to my provider and appropriate healthcare personnel involved in my care
Financial Responsibility
Laboratory services may be billed separately by the performing laboratory
I am responsible for costs not covered by insurance
It is my responsibility to verify coverage with my insurance provider
Patient Acknowledgment
I have had the opportunity to ask questions
My questions have been answered to my satisfaction
I may withdraw consent at any time prior to specimen collection
Consent
By signing below, I acknowledge that I have read and understand this form and voluntarily consent to laboratory
specimen collection.
Electronic Communication Consent
Electronic Communication Consent
The Neighborhood Clinic may communicate with patients electronically to improve access and care coordination.
Communications may include appointment reminders, patient portal messages, email communication, text reminders,
and follow-up instructions.
Types of Communication May Include
Appointment scheduling and reminders, general health updates, care coordination between providers, medication and
prescription updates, referral information, billing or insurance-related inquiries, and responses to non-urgent patient
questions.
Risks of Electronic Communication
While reasonable safeguards are used, electronic communication may carry risks such as unauthorized access.
Patient Responsibilities
Provide accurate contact information and notify the clinic if it changes.
Electronic communication should not be used for emergencies. In an emergency, call 911.
You may withdraw consent for electronic communication at any time by notifying our office.
Derechos y Responsabilidades del Paciente
Derechos y Responsabilidades del Paciente
Responsabilidades del Paciente
1. Proporcionar Información Precisa
Compartir información completa y veraz sobre su historial médico, medicamentos, síntomas y cambios en su salud
Informar a la clínica sobre cambios en su información de contacto o cobertura de seguro
Participar en su Atención
Hacer preguntas cuando no entienda su atención o plan de tratamiento
Seguir los planes de tratamiento acordados o discutir alternativas si surgen inquietudes
Asistir a las citas programadas o notificar con anticipación si necesita cancelar
Respetar el Entorno de la Clínica
Tratar al personal, proveedores y otros pacientes con cortesía y respeto
Abstenerse de comportamientos disruptivos, abusivos, amenazantes o violentos
Cumplir con normas relacionadas con seguridad, control de infecciones y conducta
4. Responsabilidad Financiera
Comprender sus beneficios y cobertura de seguro
Pagar copagos, deducibles o saldos según se requiera, o establecer planes de pago cuando corresponda
Uso Apropiado de los Servicios
Utilizar los servicios de emergencia de manera adecuada y comprender los procedimientos fuera del horario laboral y
de atención urgente
Seguir las políticas relacionadas con recetas, renovaciones y sustancias controladas
Derechos del Paciente
Atención Respetuosa y Sin Discriminación
Recibir atención con dignidad, respeto y cortesía
Ser tratado sin discriminación por raza, color, origen étnico, nacionalidad, idioma, religión, sexo, identidad de género,
orientación sexual, edad, discapacidad, estado civil, estatus de veterano o capacidad de pago
Privacidad y Confidencialidad
Tener su información de salud protegida conforme a HIPAA y leyes estatales aplicables
Recibir atención en un entorno que respeta su privacidad
Revisar, solicitar copias o pedir correcciones de sus registros médicos
Atención Informada y Toma de Decisiones
Recibir explicaciones claras sobre diagnóstico, opciones, riesgos y beneficios
Hacer preguntas y recibir respuestas antes de aceptar tratamiento
Participar activamente en decisiones sobre su atención
Aceptar o rechazar tratamiento en la medida permitida por la ley
Acceso a la Atención
Recibir atención médica y de salud conductual adecuada independientemente de seguro o capacidad de pago
Solicitar asistencia lingüística sin costo, incluidos intérpretes
Recibir adaptaciones razonables para discapacidades
5. Transparencia
Recibir información sobre políticas, tarifas, prácticas de facturación y opciones de pago
Conocer la identidad y función de los profesionales de la salud involucrados en su atención
Seguridad y Calidad
Recibir atención en un entorno seguro
Estar libre de abuso, negligencia, acoso o explotación
Expresar inquietudes sobre seguridad o calidad sin temor a represalias
Quejas y Reclamaciones
Presentar una queja o reclamación sobre su atención o servicios
Recibir información sobre cómo presentar inquietudes y esperar seguimiento oportuno
Contactar a agencias reguladoras correspondientes si sus inquietudes no se resuelven
Behavioral Health Informed Consent
This informed consent describes important information regarding behavioral health services provided by The Neighborhood Clinic. Please review this information carefully before electronically signing.
Nature Of Services And Confidentiality
Behavioral health treatment is a collaborative process. Benefits cannot be guaranteed, and discussing difficult experiences may temporarily increase emotional distress.
Behavioral health information is confidential except when disclosure is authorized, permitted, or required by law. Limits may include suspected abuse or neglect, serious risk of harm, valid court orders, professional consultation or supervision, and insurance or billing functions.
For minor clients, parent or guardian access and communication will follow applicable law, consent documents, court orders, and clinic policy.
Telehealth, Communication, Fees And Attendance
For telehealth visits, the client must provide their current physical location and be located in a state where the clinician is authorized to practice.
Email and text may not be fully secure and should generally be limited to scheduling and administrative communication.
A $100 late-cancellation or no-show fee may apply when at least 24 hours' notice is not provided. Arrivals more than 15 minutes late may be treated as a no-show. No fee applies when the clinic closes because of inclement weather or another clinic-directed closure.
A card on file may be required in accordance with clinic policy.
Emergencies And Treatment
The Neighborhood Clinic does not provide continuous emergency coverage. For immediate danger or a medical emergency, call 911 or go to the nearest emergency department. For suicide or crisis support, call or text 988.
Treatment may be ended, transferred, or referred when clinically appropriate, including for repeated missed appointments, nonpayment, failure to participate, needs outside the clinician's scope, ethical concerns, conflicts of interest, threatening or inappropriate behavior, or the need for a different level of care.
Acknowledgment And Consent
I understand the nature and general expectations of behavioral health treatment, confidentiality protections and limitations, telehealth requirements, attendance and fee policies, emergency procedures, and circumstances in which treatment may be transferred or ended.
By electronically signing below, I acknowledge that I have read and understand this Behavioral Health Informed Consent and voluntarily consent to behavioral health assessment and treatment through The Neighborhood Clinic.
Collateral Participation Agreement
This agreement applies when a family member, partner, caregiver, friend, or other individual participates in a behavioral health session for the purpose of supporting the treatment of an identified client.
Purpose Of Participation
A collateral participant may participate when involvement is appropriate to support the identified client's treatment. The identified client remains the individual receiving behavioral health services from The Neighborhood Clinic.
Participation does not create a separate therapist-client, clinician-patient, or other treatment relationship between the clinician and the collateral participant.
Voluntary Participation
Participation is voluntary. The collateral participant may choose not to participate or may leave the session at any time.
The clinician may limit or discontinue collateral participation when clinically appropriate or when continued participation may interfere with the client's treatment, privacy, safety, or therapeutic relationship.
Confidentiality And Privacy
The collateral participant agrees to respect the privacy of the identified client and the confidentiality of information learned or discussed during the session.
The Neighborhood Clinic cannot guarantee that a collateral participant will maintain confidentiality after information has been shared during a session.
Participation does not automatically authorize access to the client's records or other protected health information. Additional information will be disclosed only with appropriate authorization or another lawful basis.
Documentation, Recording And Clinical Decision-Making
The clinician may document the collateral participant's attendance, involvement, observations, statements, or other clinically relevant information in the identified client's record.
Audio recording, video recording, photography, screenshots, or other recording of a behavioral health session is not permitted without prior authorization from The Neighborhood Clinic and all appropriate participants.
Participation does not give the collateral participant authority to direct the client's treatment. Clinical decisions remain based on the client's treatment needs, professional standards, clinician judgment, and applicable law.
Acknowledgment
By electronically signing below, I acknowledge that I have read and understand this Collateral Participation Agreement, understand that I am not the clinician's client unless a separate treatment relationship is established, agree to respect the privacy of the identified client, and voluntarily agree to participate under these conditions.
Court-Involved Therapy Acknowledgment
This acknowledgment applies when behavioral health treatment involves, or may become involved with, a court proceeding, custody matter, legal dispute, attorney request, subpoena, or other legal process.
Purpose Of Treatment
The clinician's role is to provide behavioral health treatment to the identified client. The treating clinician is not serving as a custody evaluator, forensic evaluator, legal advocate, investigator, or expert witness unless a separate written agreement specifically establishes such a role.
Treatment is intended to address the client's behavioral health needs and should not be used primarily to obtain evidence, influence litigation, or gain an advantage in a legal or custody proceeding.
Clinical Opinions And Recommendations
Clinical opinions or recommendations are limited to the clinician's professional role, scope of practice, available information, and direct clinical observations.
Participation in treatment does not guarantee that the clinician will provide an opinion, recommendation, letter, declaration, affidavit, testimony, or other statement for use in a legal proceeding.
Court, Custody And Legal Requests
The Neighborhood Clinic should be informed promptly of court orders, custody or guardianship agreements, parenting plans, legal restrictions, subpoenas, attorney requests, pending litigation involving treatment, or expectations that the clinician participate in a legal proceeding.
Current legal documentation may be required when custody, consent, access to records, or participation in treatment is disputed.
Behavioral health records and communications remain subject to applicable confidentiality and privacy requirements. A subpoena, attorney request, or other demand does not necessarily mean that confidential information will automatically be released.
Children And Families
When treatment involves a child or adolescent, the clinician's primary role remains therapeutic. Parents, guardians, family members, attorneys, and other parties should not pressure the clinician to take sides, make custody recommendations, or use the therapeutic relationship to gain an advantage in litigation.
Therapeutic statements, play, artwork, or other information arising during treatment should not automatically be interpreted as forensic evidence or proof of events outside the therapeutic context.
Acknowledgment
By electronically signing below, I acknowledge that I have read and understand this Court-Involved Therapy Acknowledgment and agree to the therapeutic-role expectations, confidentiality limitations, and legal-request procedures described above.
Insurance Opt-Out Agreement
This agreement applies when a client voluntarily chooses not to use available health insurance benefits for behavioral health services provided by The Neighborhood Clinic.
Voluntary Election
I voluntarily choose not to use my health insurance benefits for the behavioral health services covered by this election. I understand that this decision is voluntary and that The Neighborhood Clinic and my clinician have not coerced, pressured, or improperly encouraged me to decline use of insurance.
Self-Pay Responsibility
I understand that I will be treated as a self-pay client for services covered by this election and accept responsibility for the applicable self-pay charges.
Payment may be required at the time services are provided in accordance with clinic policy.
Insurance Claims And Coverage
I request that The Neighborhood Clinic not submit claims to my health insurance for services covered by this agreement, to the extent permitted by applicable law and payer requirements.
I understand that laws, payer rules, government program requirements, or contractual obligations may limit when a service can be provided on a self-pay basis without billing available coverage.
Deductibles, Reimbursement And Changes
Amounts I pay directly may not count toward my deductible, copayment, coinsurance, or annual out-of-pocket maximum. The Neighborhood Clinic does not guarantee reimbursement from my insurance company.
I agree to notify the clinic promptly if my insurance changes or if I later decide to use insurance. Any approved change will apply prospectively and will not automatically be backdated.
Acknowledgment
By electronically signing below, I acknowledge that I have read and understand this Insurance Opt-Out Agreement and voluntarily elect to receive the applicable behavioral health services on a self-pay basis, subject to applicable law and payer requirements.
Minor Behavioral Health Records Authorization
This authorization applies when a parent, legal guardian, or other legally authorized representative requests release of behavioral health records relating to a minor receiving services through The Neighborhood Clinic.
Authority To Authorize Release
By signing this authorization, I certify that I am legally authorized to request and authorize release of the minor's behavioral health information.
The Neighborhood Clinic may require verification of identity and legal authority, including current custody, guardianship, parental-rights, or court documentation.
Being a parent or guardian does not necessarily provide unrestricted access to all behavioral health information in every circumstance. Access and disclosure will be determined in accordance with applicable law, the minor's rights, court orders, consent requirements, and clinic policy.
Records And Sensitive Information
Behavioral health records may include assessments, diagnoses, treatment plans, progress notes, medication information, care coordination, discharge information, and other behavioral health information maintained in the clinical record.
Certain information may be subject to additional federal or state confidentiality protections and may require additional authorization or may not be released in certain circumstances.
Purpose, Disclosure And Revocation
Only information reasonably necessary and legally permitted for the authorized disclosure will be released. The clinic may require additional information about the intended recipient, purpose, requested records, or delivery method before processing the request.
Once information is disclosed to an authorized recipient, The Neighborhood Clinic may no longer control how the recipient uses, stores, or rediscloses it.
I may revoke this authorization in writing, subject to applicable law. Revocation will not affect information already disclosed or actions already taken in reliance on the authorization.
Court Orders, Custody And Minor Privacy
If there is a custody dispute, court order, guardianship matter, restriction on access, or disagreement regarding authority, The Neighborhood Clinic may require current legal documentation and may delay release while reviewing the issue.
This authorization does not automatically override confidentiality protections or privacy rights that may apply to the minor under federal or state law.
Acknowledgment
By electronically signing below, I certify that I have legal authority to authorize the applicable release, acknowledge the sensitive nature of behavioral health information, and authorize The Neighborhood Clinic to release information in accordance with my request, applicable law, and clinic policy.
HIPAA Authorization And Notice Of Privacy Practices Acknowledgment
The Neighborhood Clinic is committed to protecting the privacy and confidentiality of your health information. This document explains how protected health information may be used and disclosed and describes your rights regarding your medical information.
Protected Health Information
Protected Health Information, or PHI, includes information that identifies you and relates to your health, healthcare services, or payment for healthcare. This may include medical history, diagnoses, medications, laboratory and imaging results, treatment information, referrals, billing, insurance information, and other information maintained in your medical record.
Treatment, Payment And Healthcare Operations
The Neighborhood Clinic may use and disclose health information as permitted for treatment, payment, and healthcare operations. This may include communication with healthcare professionals and organizations involved in your care, insurance eligibility and claims activities, quality improvement, compliance, auditing, credentialing, and other lawful clinic operations.
Other Uses And Electronic Information
Health information may also be used or disclosed when permitted or required by law, including certain public health, safety, oversight, workers' compensation, judicial, law-enforcement, and reporting activities.
The Neighborhood Clinic may maintain and exchange health information electronically through authorized healthcare technology and uses reasonable safeguards to protect that information.
Communication And People Involved In Your Care
The Neighborhood Clinic may contact you regarding appointments, results, prescriptions, referrals, billing, insurance, or other healthcare-related matters through appropriate communication methods.
When permitted by law and appropriate under the circumstances, limited information may be shared with a family member, caregiver, or other person involved in your care or payment for your care.
Your Privacy Rights
Your rights may include requesting access to or a copy of your medical record, requesting an amendment, requesting certain restrictions or confidential communications, requesting an accounting of certain disclosures, receiving the clinic's Notice of Privacy Practices, and filing a privacy complaint without retaliation.
Certain uses or disclosures may require a separate written authorization. A separate authorization may generally be revoked in writing except to the extent action has already been taken in reliance on it or as otherwise permitted by law.
Acknowledgment
By electronically signing below, I acknowledge that I have been provided access to The Neighborhood Clinic's Notice of Privacy Practices, understand that my information may be used or disclosed for treatment, payment, healthcare operations, and other purposes permitted or required by law, and understand that certain uses or disclosures may require separate authorization.
Consentimiento Para Extracción De Sangre
Este consentimiento autoriza a The Neighborhood Clinic y a su personal clínico capacitado a realizar una extracción de sangre o recolectar otras muestras cuando sea médicamente indicado u ordenado como parte de su atención.
Propósito De Las Pruebas De Laboratorio
Las pruebas de laboratorio pueden utilizarse para detección, diagnóstico, tratamiento, monitoreo de condiciones médicas, manejo de medicamentos, atención preventiva u otros propósitos clínicamente apropiados.
Las muestras pueden incluir sangre, orina, hisopos u otras muestras biológicas apropiadas.
Procedimiento Y Riesgos
La extracción de sangre generalmente implica insertar una aguja estéril en una vena, usualmente del brazo o la mano, para obtener una o más muestras. En algunos casos puede ser necesario más de un intento.
Los posibles riesgos incluyen dolor, sensibilidad, moretones, sangrado, hinchazón, hematoma, mareos, desmayo, dificultad para obtener una muestra, infección poco frecuente o irritación o lesión nerviosa poco frecuente.
Información Que Debo Proporcionar
Debo informar al personal si tengo antecedentes de desmayos, extracciones difíciles, trastornos de sangrado, uso de anticoagulantes, alergias a adhesivos o antisépticos, o cualquier otra condición que pueda afectar la recolección segura.
Debo informar inmediatamente si siento dolor significativo, entumecimiento, mareo, náuseas u otros síntomas preocupantes.
Procesamiento, Resultados Y Facturación
Las muestras pueden procesarse en The Neighborhood Clinic o enviarse a un laboratorio externo. Puede ser necesario repetir una muestra si resulta insuficiente o inadecuada.
Los laboratorios externos pueden facturar por separado. La cobertura depende de mi seguro, beneficios, deducible, copago, coseguro y otros requisitos aplicables.
Derecho A Preguntar O Rechazar
Puedo hacer preguntas o rechazar la extracción antes de que se realice. Entiendo que rechazar pruebas recomendadas puede limitar la capacidad de mi proveedor para evaluar, diagnosticar, monitorear o tratar mi condición.
Reconocimiento Y Consentimiento
Al firmar electrónicamente a continuación, confirmo que he leído y comprendido este Consentimiento Para Extracción De Sangre y autorizo voluntariamente a The Neighborhood Clinic y a su personal clínico capacitado a realizar las extracciones y recolecciones de muestras médicamente apropiadas.
Consentimiento Para Comunicaciones Electrónicas
The Neighborhood Clinic utiliza diferentes métodos de comunicación electrónica para facilitar la comunicación relacionada con su atención médica y asuntos administrativos.
Métodos Y Tipos De Comunicación
The Neighborhood Clinic puede comunicarse por mensaje de texto, correo electrónico, teléfono, correo de voz, portal del paciente, sistemas automatizados de recordatorios u otros métodos electrónicos apropiados.
Las comunicaciones pueden incluir citas, programación, resultados, medicamentos, resurtidos, referencias, autorizaciones, formularios, facturación, seguros, notificaciones del portal e instrucciones generales relacionadas con su atención.
Privacidad Y Seguridad
Entiendo que mensajes de texto, correos electrónicos y correos de voz estándar pueden no ser completamente seguros. Otra persona con acceso a mi dispositivo o cuenta podría ver o escuchar una comunicación.
The Neighborhood Clinic tomará medidas razonables para proteger la privacidad, pero no puede garantizar la seguridad absoluta de métodos electrónicos no cifrados.
Responsabilidad Del Paciente
Es mi responsabilidad mantener actualizada mi información de contacto y proteger el acceso a mis dispositivos, cuentas, correo de voz y portal del paciente.
Si proporciono un número telefónico o correo electrónico compartido, entiendo que otra persona puede tener acceso a las comunicaciones.
Emergencias Y Tiempos De Respuesta
Las comunicaciones electrónicas no se monitorean continuamente y no deben utilizarse para emergencias médicas. Si tengo una emergencia, debo llamar al 911 o acudir al departamento de emergencias más cercano.
Preferencias Y Retiro Del Consentimiento
Puedo solicitar cambios en mis preferencias o retirar mi consentimiento para ciertas comunicaciones electrónicas. Esto no afectará mi derecho a recibir atención médicamente apropiada, aunque la clínica aún puede comunicarse cuando sea permitido o requerido por la ley.
Reconocimiento Y Consentimiento
Al firmar electrónicamente a continuación, confirmo que he leído y comprendido este Consentimiento Para Comunicaciones Electrónicas y autorizo a The Neighborhood Clinic a comunicarse conmigo mediante los métodos electrónicos apropiados utilizando la información de contacto que he proporcionado.
Testosterone Therapy Agreement And Informed Consent
This agreement provides important information regarding testosterone therapy, including potential benefits, risks, limitations, monitoring requirements, and patient responsibilities.
Purpose Of Testosterone Therapy
Testosterone therapy may be prescribed when clinically appropriate based on symptoms, medical history, examination, laboratory findings, and provider judgment. Potential benefits may include improvement in energy, sexual function, mood, muscle mass, strength, bone health, or other symptoms, but results cannot be guaranteed.
Medication And Treatment Plan
Testosterone must be used only as prescribed. I will not independently change the dose, frequency, route, or schedule. Treatment may be adjusted or discontinued based on symptoms, laboratory results, side effects, medical conditions, treatment response, or provider judgment.
Potential Risks And Side Effects
Potential risks and side effects may include acne, oily skin, hair changes, fluid retention, mood or libido changes, breast tenderness, cholesterol changes, increased hematocrit, worsening untreated sleep apnea, blood pressure changes, prostate-related symptoms in patients with a prostate, reduced testicular size, reduced sperm production, and impaired fertility.
Other risks may occur and individual risk varies based on medical history and other medications or conditions.
Fertility And Reproductive Considerations
Testosterone can significantly reduce sperm production and may impair fertility. Testosterone therapy should not be considered contraception. Patients planning biological children should discuss fertility goals before beginning or continuing treatment.
Patients who could become pregnant should discuss pregnancy potential, contraception, and reproductive plans with their provider.
Monitoring And Follow-Up
Regular follow-up and laboratory testing are important for safe treatment and may include testosterone levels, complete blood count, hematocrit, and other tests considered clinically appropriate.
Prescriptions or refills may be delayed, limited, or discontinued when required follow-up or monitoring is not completed or when continued therapy is not medically appropriate.
Medication Safety
Testosterone is a controlled medication. I will use it only as prescribed, keep it secure, never share or sell it, follow storage and disposal instructions, and inform my provider about other medications, hormones, supplements, or substances I use.
Acknowledgment And Consent
By electronically signing below, I acknowledge that I have read and understand this Testosterone Therapy Agreement And Informed Consent, understand the potential benefits, risks, alternatives, fertility implications, and monitoring requirements, and voluntarily consent to therapy as prescribed.
Autorización HIPAA Y Reconocimiento Del Aviso De Prácticas De Privacidad
The Neighborhood Clinic se compromete a proteger la privacidad y confidencialidad de su información médica. Este documento explica cómo su Información Médica Protegida puede ser utilizada y divulgada y describe sus derechos.
Información Médica Protegida
La Información Médica Protegida, o PHI, incluye información que puede identificarle y que está relacionada con su salud, servicios de atención médica o pago de dichos servicios.
Tratamiento, Pago Y Operaciones
The Neighborhood Clinic puede utilizar y divulgar información según sea necesario para tratamiento, pago y operaciones de atención médica, incluyendo coordinación de atención, recetas, laboratorios, referencias, verificación de seguros, reclamaciones, facturación, calidad, cumplimiento y otras operaciones legales.
Otros Usos Y Divulgaciones Permitidos
La información también puede utilizarse o divulgarse cuando sea permitido o requerido por la ley, incluyendo ciertas actividades de salud pública, seguridad, supervisión, compensación laboral, procedimientos judiciales, autoridades y otros informes legales.
Comunicaciones Y Personas Involucradas En Su Atención
The Neighborhood Clinic puede comunicarse con usted sobre citas, resultados, recetas, referencias, facturación, seguros u otros asuntos de atención. Cuando sea permitido por la ley, puede compartirse información limitada con familiares, cuidadores u otras personas involucradas en su atención.
Sus Derechos De Privacidad
Sus derechos pueden incluir solicitar acceso o copias de su expediente, solicitar modificaciones, pedir ciertas restricciones o comunicaciones confidenciales, solicitar un registro de determinadas divulgaciones, recibir el Aviso de Prácticas de Privacidad y presentar una queja sin represalias.
Ciertos usos o divulgaciones pueden requerir una autorización adicional por escrito.
Reconocimiento
Al firmar electrónicamente a continuación, confirmo que se me ha proporcionado acceso al Aviso de Prácticas de Privacidad de The Neighborhood Clinic y que comprendo los usos y divulgaciones descritos y mis derechos de privacidad.
Therapy Groups Disclosure Statement
Group therapy provides an opportunity to participate in behavioral health treatment with others who may share similar concerns, experiences, or treatment goals. Because multiple participants are involved, group therapy has unique confidentiality considerations.
Purpose And Voluntary Participation
Therapy groups may provide education, emotional support, coping skills, communication practice, and therapeutic discussion facilitated by a qualified clinician. Participation does not guarantee a particular outcome.
Participation is voluntary unless separately required by another program, court order, or treatment arrangement. The clinician may recommend another group, individual therapy, a different level of care, or another treatment option when appropriate.
Confidentiality Within The Group
The Neighborhood Clinic and its clinicians are required to protect patient information under applicable privacy requirements. Other group participants are not clinic employees or healthcare providers, and the clinic cannot guarantee that another participant will maintain confidentiality outside the group.
Participants are expected not to disclose another group member's identity or personal information learned during a group session.
Respectful And Safe Participation
Participants are expected to communicate respectfully and support the emotional and physical safety of the group. Threatening, intimidating, discriminatory, sexually inappropriate, harassing, abusive, or disruptive behavior is not permitted.
The clinician may redirect discussion, establish boundaries, ask a participant to leave, or discontinue participation when behavior interferes with safety or the therapeutic purpose of the group.
Recording, Outside Contact And Telehealth
Audio or video recording, photography, screenshots, or other recording of a therapy group is prohibited unless specifically authorized.
For telehealth groups, participants are responsible for joining from a reasonably private location and taking steps to prevent others from seeing or hearing the session.
Documentation And Emergencies
The clinician may document clinically relevant information regarding attendance, participation, treatment progress, symptoms, risk concerns, interventions, or response to treatment in the participant's medical record.
Group therapy is not an emergency service. For immediate danger or a medical emergency, call 911 or go to the nearest emergency department. For suicide or crisis support, call or text 988.
Acknowledgment And Consent
By electronically signing below, I acknowledge that I have read and understand this Therapy Groups Disclosure Statement, understand the limits of confidentiality associated with group therapy, agree to respect the privacy of other participants, and voluntarily consent to participate.
Patient Rights And Responsibilities
The Neighborhood Clinic is committed to providing respectful, safe, accessible, and high-quality healthcare. As a patient, you have rights regarding your care and responsibilities that help support a safe and effective healthcare environment.
Your Rights
You have the right to considerate, respectful, and compassionate care without discrimination; to be treated with dignity; and to receive care in a reasonably safe environment.
You have the right to participate in healthcare decisions, receive understandable information about your condition and recommended care, ask questions, and accept or refuse treatment except when otherwise permitted or required by law.
You have the right to reasonable privacy and confidentiality, access to your health information as permitted by law, communication assistance and accessibility support when required, information about your care team and applicable costs, and the ability to voice concerns or complaints without retaliation.
Your Responsibilities
You are responsible for providing complete and accurate health, medication, allergy, insurance, and contact information and notifying the clinic of important changes.
You are responsible for asking questions when you do not understand your care, participating in agreed-upon treatment plans, attending appointments, and notifying the clinic when you cannot attend.
You are responsible for applicable financial obligations and for treating staff, providers, patients, and visitors with courtesy and respect.
Safety And Privacy
Threatening, abusive, discriminatory, harassing, sexually inappropriate, intimidating, violent, or disruptive behavior is not permitted. Behavior that threatens safety may result in removal, appropriate authority involvement, or termination of the patient-provider relationship when legally and clinically appropriate.
You are expected to respect the privacy of other patients and may not record or photograph another patient or private clinical activity without appropriate authorization.
Emergencies
The Neighborhood Clinic provides outpatient services and is not a substitute for emergency care. If you are experiencing a medical emergency or immediate danger, call 911 or go to the nearest emergency department.
Acknowledgment
By electronically signing below, I acknowledge that I have received, read, and understand The Neighborhood Clinic's Patient Rights And Responsibilities and have had the opportunity to ask questions.
Consentimiento Para Servicios De Telesalud
La telesalud permite que The Neighborhood Clinic proporcione determinados servicios de atención médica mediante tecnología de comunicación electrónica cuando sea clínicamente apropiado.
Qué Es La Telesalud
La telesalud puede incluir consultas, seguimiento, revisión de resultados, manejo de medicamentos, evaluación de síntomas, educación, coordinación de atención y otros servicios que el proveedor considere apropiados para realizar de manera virtual.
Ubicación Del Paciente
Al comienzo de cada visita se me puede solicitar que confirme mi ubicación física actual. Debo estar físicamente ubicado en un estado donde mi proveedor esté legalmente autorizado para brindar atención.
Beneficios, Riesgos Y Limitaciones
Los posibles beneficios incluyen mayor acceso, menos viajes y mayor conveniencia. Los riesgos pueden incluir fallas tecnológicas, interrupciones, calidad limitada de audio o video, limitaciones del examen físico, información clínica incompleta y riesgos de privacidad o seguridad.
Mi proveedor puede recomendar una evaluación presencial, laboratorio, imágenes, especialista, atención urgente o departamento de emergencias cuando sea médicamente apropiado.
Privacidad, Grabación Y Personas Presentes
The Neighborhood Clinic tomará medidas razonables para proteger la privacidad y confidencialidad. Debo participar desde un lugar razonablemente privado cuando sea posible e informar si otra persona está presente.
No debo grabar, fotografiar, capturar pantalla o distribuir una visita sin autorización previa.
Medicamentos, Fallas Tecnológicas Y Emergencias
Una visita de telesalud no garantiza que se recetará o renovará un medicamento. Ciertos medicamentos pueden requerir evaluación presencial, pruebas o monitoreo.
Si la tecnología falla, la visita puede reconectarse, cambiarse a otro método apropiado o reprogramarse.
La telesalud no sustituye la atención de emergencia. Si tengo una emergencia médica, debo llamar al 911 o acudir al departamento de emergencias más cercano.
Reconocimiento Y Consentimiento
Al firmar electrónicamente a continuación, confirmo que he leído y comprendido este Consentimiento Para Servicios De Telesalud y acepto voluntariamente recibir servicios de telesalud cuando sean clínicamente apropiados.
Consent To Treat An Unaccompanied Minor
This consent allows The Neighborhood Clinic to provide medically appropriate healthcare services to a minor when the minor's parent or legal guardian is not physically present for the visit.
Authorization For Treatment
I authorize The Neighborhood Clinic and its qualified healthcare professionals to provide routine and medically appropriate healthcare services to the minor in my absence, including medical evaluation, preventive care, treatment of illness or injury, routine laboratory and diagnostic testing, medications, referrals, and follow-up when clinically appropriate.
Limitations And Communication
This consent does not require the clinic to perform a service that is inappropriate, unsafe, outside scope, or requires additional consent. Certain services may require the parent or legal guardian to be present.
The clinic may contact the parent or legal guardian during or after the visit when necessary. Non-emergency care may be delayed or rescheduled if appropriate authorization cannot be obtained.
Medications, Testing And Privacy
I authorize clinically appropriate medications and routine laboratory or diagnostic testing. Certain medications, tests, or procedures may require additional consent or evaluation.
Healthcare involving minors is subject to federal and state privacy and consent laws. This authorization does not override privacy, confidentiality, or consent rights provided to a minor under applicable law.
Emergency And Financial Responsibility
If an emergency occurs while the minor is at the clinic, staff may provide appropriate assistance and contact emergency medical services. For a medical emergency before arrival, call 911 or go to the nearest emergency department.
This authorization does not change the financial responsibility for the minor's care.
Parent Or Guardian Certification
By signing, I certify that I am the minor's parent, legal guardian, or another person legally authorized to consent to healthcare and will notify The Neighborhood Clinic of any court order, custody restriction, or other limitation affecting my authority.
Acknowledgment And Consent
By electronically signing below, I acknowledge that I have read and understand this Consent To Treat An Unaccompanied Minor and authorize medically appropriate outpatient care to the minor in my absence, subject to applicable law and clinic policy.
Controlled Substance Treatment Agreement
Controlled medications require careful prescribing, monitoring, and patient participation to promote safe and appropriate treatment. This agreement describes expectations associated with receiving a controlled substance prescription from The Neighborhood Clinic.
Purpose And Medication Use
Controlled substances may be prescribed when the treating provider determines the potential benefits outweigh the risks and treatment is clinically appropriate. Signing this agreement does not guarantee that a controlled substance will be prescribed or continued.
I agree to take controlled medication exactly as prescribed and will not independently change the dose, frequency, route, or schedule. I will not use another person's medication or allow another person to use mine.
Prescribers, Pharmacies And PDMP
I agree to inform The Neighborhood Clinic of controlled substances prescribed by other healthcare professionals. When clinically appropriate, I may be asked to use one primary prescriber or care team and one pharmacy.
I understand that The Neighborhood Clinic may review applicable Prescription Drug Monitoring Program information before and during controlled-substance treatment.
Monitoring And Follow-Up
When clinically appropriate and permitted by law, I may be asked to complete urine, blood, saliva, or other medication monitoring, medication reconciliation or counts, laboratory testing, vital-sign monitoring, or other safety measures.
I agree to attend required follow-up appointments. Prescriptions may be delayed, limited, modified, tapered, or discontinued when required monitoring or follow-up is not completed.
Refills, Lost Medication And Storage
Early refills are not guaranteed. Lost, stolen, damaged, destroyed, or misplaced controlled medication may not be replaced early, and a police report does not guarantee replacement.
I will store controlled medication securely and will never sell, share, trade, loan, or give it to another person.
Alcohol, Other Substances And Safety
I will inform my provider about relevant alcohol, cannabis, medications, supplements, and other substances because combinations may create dangerous interactions. I will follow safety instructions and avoid driving or hazardous activity when impaired.
Tapering Or Discontinuation
Controlled medication may be reduced, tapered, changed, or discontinued when continued treatment is no longer safe, effective, appropriate, or medically indicated, including for concerning monitoring results, unsafe combinations, misuse, diversion, repeated early refill requests, failure to follow monitoring, or significant agreement violations.
Acknowledgment And Agreement
By electronically signing below, I acknowledge that I have read and understand this Controlled Substance Treatment Agreement and agree to follow these requirements while receiving controlled-substance treatment through The Neighborhood Clinic.
Consentimiento Para Recibir Tratamiento
Este consentimiento autoriza a The Neighborhood Clinic y a sus profesionales de atención médica a proporcionar servicios médicamente apropiados para evaluación, diagnóstico, tratamiento y atención continua.
Consentimiento Para Atención Médica
Autorizo voluntariamente a The Neighborhood Clinic y a sus profesionales calificados a proporcionar evaluación, diagnóstico, tratamiento y otros servicios clínicamente apropiados dentro de su ámbito de práctica.
Servicios Médicos
Los servicios pueden incluir evaluación de síntomas, exámenes físicos, atención preventiva, manejo de condiciones agudas y crónicas, signos vitales, pruebas de laboratorio, recolección de muestras, pruebas diagnósticas, medicamentos, inyecciones, referencias, seguimiento y educación.
Consentimiento Informado Y Medicamentos
Tengo derecho a recibir información sobre tratamientos, pruebas, medicamentos o procedimientos recomendados, incluyendo beneficios, riesgos significativos y alternativas razonables cuando corresponda, y a hacer preguntas antes de aceptar.
Entiendo que ciertos servicios pueden requerir consentimiento adicional y que recibir atención no garantiza que se recetará un medicamento específico.
Pruebas, Referencias Y Participación
Autorizo pruebas de laboratorio y diagnóstico médicamente apropiadas. Algunos servicios pueden ser realizados por organizaciones externas y generar cargos separados.
Me comprometo a proporcionar información completa y precisa y a participar en el seguimiento recomendado.
Derecho A Rechazar, Privacidad Y Emergencias
Puedo rechazar tratamiento salvo cuando la ley disponga lo contrario. Mi información será protegida de acuerdo con las leyes aplicables y el Aviso de Prácticas de Privacidad.
The Neighborhood Clinic es una clínica ambulatoria. Para una emergencia médica debo llamar al 911 o acudir al departamento de emergencias más cercano.
Reconocimiento Y Consentimiento
Al firmar electrónicamente a continuación, confirmo que he leído y comprendido este Consentimiento Para Recibir Tratamiento y autorizo voluntariamente a The Neighborhood Clinic a proporcionar servicios médicamente apropiados.
Acuerdo De Responsabilidad Financiera
Este acuerdo explica sus responsabilidades financieras relacionadas con los servicios proporcionados por The Neighborhood Clinic.
Información Del Seguro Y Verificación De Beneficios
Es mi responsabilidad proporcionar información de seguro completa, correcta y actualizada y notificar cualquier cambio.
La verificación de elegibilidad o beneficios no garantiza cobertura ni pago. Soy responsable de comprender los beneficios, exclusiones, limitaciones y requisitos de mi plan.
Copagos, Deducibles Y Coseguro
Acepto pagar las cantidades que legal y contractualmente sean mi responsabilidad, incluyendo copagos, deducibles, coseguro, servicios no cubiertos, servicios excluidos y otras cantidades asignadas por mi seguro.
Autorizaciones, Referencias Y Servicios No Cubiertos
Algunos planes requieren autorización o referencia. Obtenerla no garantiza pago. Cuando sea permitido por la ley y contratos aplicables, puedo ser responsable de servicios no cubiertos o denegados.
Laboratorios, Imágenes Y Servicios Externos
Laboratorios, centros de imágenes, especialistas, farmacias u otros proveedores externos pueden facturar por separado. Soy responsable de verificar participación y cobertura cuando corresponda.
Pago Directo, Saldos Y Método De Pago
Si soy paciente de pago directo para determinados servicios, acepto pagar las tarifas aplicables. Soy responsable de saldos legítimos y de comunicarme con la clínica si considero que un saldo es incorrecto.
The Neighborhood Clinic puede requerir un método de pago válido registrado de acuerdo con sus políticas y la ley aplicable.
Facturación A Mi Seguro
Autorizo a The Neighborhood Clinic a presentar reclamaciones, proporcionar la información razonablemente necesaria y recibir el pago directo de beneficios cuando sea permitido. Esto no elimina mi responsabilidad por cantidades correctamente asignadas al paciente.
Reconocimiento
Al firmar electrónicamente a continuación, confirmo que he leído y comprendido este Acuerdo De Responsabilidad Financiera y acepto la responsabilidad financiera correspondiente de acuerdo con mi cobertura, la ley aplicable y las políticas de la clínica.
Disclosure And Consent To Injection Treatment
This consent provides important information regarding medications, vitamins, vaccines, or other therapeutic substances administered by injection at The Neighborhood Clinic.
Purpose And Administration
Injection therapy may be used to administer a medication, vitamin, vaccine, supplement, or other therapeutic substance as part of an individualized treatment plan.
Depending on the treatment, an injection may be administered into the muscle, underneath the skin, or by another medically appropriate method by trained clinical personnel.
Benefits, Risks And Side Effects
Potential benefits depend on the substance administered and cannot be guaranteed.
Possible injection-related risks include pain, tenderness, redness, swelling, bruising, bleeding, numbness or tingling, local irritation, infection, dizziness, fainting, nausea, headache, allergic reaction, and medication-specific side effects. Rarely, serious reactions may occur.
Medical History, Pregnancy And Allergies
I agree to provide accurate information regarding my medical history, medications, supplements, allergies, previous reactions, pregnancy or breastfeeding status when relevant, and other information needed to assess safe treatment.
Monitoring And Alternatives
Follow-up, laboratory testing, vital-sign monitoring, or additional evaluation may be recommended. Treatment may be adjusted, delayed, or discontinued based on response, side effects, results, or changes in health.
I may discuss reasonable alternatives and have the right to ask questions or refuse an injection before it is administered.
Emergency Care
A severe allergic reaction or other life-threatening reaction is a medical emergency. If I experience difficulty breathing, loss of consciousness, severe chest pain, severe swelling, or other life-threatening symptoms, I should call 911 or obtain immediate emergency care.
Acknowledgment And Consent
By electronically signing below, I acknowledge that I have read and understand this Disclosure And Consent To Injection Treatment and voluntarily authorize The Neighborhood Clinic and qualified clinical personnel to administer injections that are ordered or clinically appropriate.
Consent To Treat
This consent authorizes The Neighborhood Clinic and its qualified healthcare professionals to provide medically appropriate healthcare services for evaluation, diagnosis, treatment, and ongoing care.
Consent For Medical Care
I voluntarily authorize The Neighborhood Clinic and qualified healthcare professionals to provide medical evaluation, diagnosis, treatment, and other healthcare services considered clinically appropriate within their respective scopes of practice.
Medical Services
Services may include evaluation of symptoms, physical examinations, preventive care, management of acute and chronic conditions, vital signs, laboratory testing and specimen collection, diagnostic testing, medications, injections, referrals, care coordination, follow-up, and patient education.
Informed Consent And Medications
I have the right to receive information about recommended treatments, tests, medications, or procedures, including expected benefits, significant risks, and reasonable alternatives when applicable, and to ask questions before agreeing.
Certain services may require separate consent. Receiving care does not guarantee that a particular medication, including a controlled substance, will be prescribed.
Laboratory Testing, Referrals And Participation
I authorize routine laboratory and diagnostic testing when medically appropriate. Outside laboratories, imaging facilities, specialists, pharmacies, or other organizations may bill separately.
I agree to provide complete and accurate information and participate in recommended follow-up.
Right To Refuse, Privacy And Financial Responsibility
I may refuse recommended care except when otherwise permitted or required by law. My health information will be handled in accordance with applicable privacy laws and the clinic's Notice of Privacy Practices.
I understand that I may be responsible for applicable copayments, deductibles, coinsurance, self-pay charges, non-covered services, and other patient-responsibility amounts.
Emergency Care
The Neighborhood Clinic provides outpatient services and is not a substitute for emergency care. For a medical emergency or potentially life-threatening symptoms, call 911 or go to the nearest emergency department.
Acknowledgment And Consent
By electronically signing below, I acknowledge that I have read and understand this Consent To Treat and voluntarily authorize medically appropriate evaluation, diagnosis, treatment, and related healthcare services.
Telehealth Consent
Telehealth allows The Neighborhood Clinic to provide certain healthcare services through electronic communication technology when clinically appropriate.
What Is Telehealth
Telehealth may include medical consultations, symptom evaluation, follow-up, chronic-condition management, medication management, review of results, patient education, care coordination, and other services appropriate for virtual care.
Patient Location
I may be required to provide my current physical location at each telehealth appointment and must be in a state where the treating provider is legally authorized to provide care.
Benefits, Risks And Limitations
Potential benefits include improved access, reduced travel, convenience, and continuity of care. Risks may include internet or technology failures, poor audio or video quality, interruptions, limitations of physical examination, incomplete clinical information, delays, and privacy or security risks.
My provider may determine that an in-person evaluation, laboratory testing, imaging, specialist evaluation, urgent care, or emergency care is necessary.
Privacy, Recording And Other Individuals
The Neighborhood Clinic will take reasonable measures to protect privacy and confidentiality. I agree to participate from a reasonably private location when possible and inform my provider if another person is present.
I will not record, photograph, capture, or distribute a telehealth visit without appropriate prior authorization.
Prescriptions, Technology Failure And Emergencies
A telehealth appointment does not guarantee that a medication will be prescribed or refilled. Certain medications may require in-person evaluation, testing, monitoring, or additional documentation.
If technology fails, the visit may be reconnected, changed to another appropriate method, or rescheduled.
Telehealth is not a substitute for emergency care. For a medical emergency, call 911 or go to the nearest emergency department.
Financial Responsibility And Right To Decline
Telehealth services may be billed to insurance when applicable, and I remain responsible for applicable patient-responsibility amounts.
I may decline telehealth or withdraw consent for future telehealth services without losing access to other medically appropriate care.
Acknowledgment And Consent
By electronically signing below, I acknowledge that I have read and understand this Telehealth Consent and voluntarily consent to telehealth services when clinically appropriate.
Financial Responsibility Agreement
This agreement explains your financial responsibilities for healthcare services provided by The Neighborhood Clinic.
Insurance Information And Benefit Verification
I am responsible for providing complete, accurate, and current insurance information and notifying The Neighborhood Clinic of changes.
Verification of eligibility or benefits is not a guarantee of coverage or payment. I am responsible for understanding the benefits, exclusions, limitations, network requirements, and other provisions of my plan.
Copayments, Deductibles And Coinsurance
I agree to pay amounts legally and contractually determined to be my responsibility, including copayments, deductibles, coinsurance, non-covered services, excluded services, and other patient-responsibility amounts.
Prior Authorizations, Referrals And Non-Covered Services
Some plans require prior authorization, referral, notification, or other approval. Obtaining authorization or referral does not guarantee coverage or payment.
When permitted by applicable law and payer contracts, I may be financially responsible for non-covered or denied services.
Outside Services
Outside laboratories, imaging facilities, specialists, pharmacies, hospitals, and other organizations may bill independently. I am responsible for verifying network participation and coverage when applicable.
Self-Pay, Balances And Payment Method
If I am self-pay for applicable services, I agree to pay current self-pay charges. I am responsible for legitimate balances and should contact the clinic if I believe a charge is incorrect.
The Neighborhood Clinic may require a valid payment method on file in accordance with current policies and applicable law.
Assignment Of Insurance Benefits
I authorize The Neighborhood Clinic to submit claims, provide information reasonably necessary to process claims or obtain payment, and receive applicable insurance benefits directly when permitted.
Acknowledgment
By electronically signing below, I acknowledge that I have read and understand this Financial Responsibility Agreement and accept financial responsibility for applicable services in accordance with my insurance benefits, applicable law, payer requirements, and clinic policies.
Consent For AI-Assisted Clinical Documentation
The Neighborhood Clinic may use secure technology that incorporates artificial intelligence, sometimes referred to as an AI scribe, ambient documentation, or AI-assisted transcription, to assist healthcare providers with documenting patient visits.
How AI-Assisted Documentation Works
An approved system may process conversation during a healthcare encounter to assist in creating a draft clinical note or related documentation.
The healthcare provider remains responsible for reviewing, editing when necessary, and approving final documentation. AI-generated documentation is not automatically accepted as the final medical record without provider review.
Purpose And Information Processed
The technology may assist with documenting clinically relevant information, summarizing the encounter, reducing manual documentation burden, and allowing the provider to focus more directly on the patient.
Information processed may include symptoms, history, medications, allergies, diagnoses, treatment information, family and social history, results, recommendations, and other information discussed during the visit.
Privacy, Audio And Accuracy
The Neighborhood Clinic will use approved technology and reasonable safeguards intended to protect patient information in accordance with applicable privacy requirements and clinic policies.
The system may process audio to generate a transcription, summary, or draft note. AI technology may make errors, omit information, misunderstand words, or incorrectly interpret portions of a conversation.
Provider Responsibility
AI-assisted documentation does not independently diagnose conditions, determine treatment plans, prescribe medications, replace professional judgment, or make final clinical decisions.
Right To Decline Or Withdraw
Participation is voluntary. I may tell my provider that I do not want AI-assisted documentation used during my visit, and declining will not prevent me from receiving medically appropriate care.
I may withdraw consent for future encounters. Withdrawal will not necessarily remove information already appropriately incorporated into the medical record or processed before withdrawal.
Acknowledgment And Consent
By electronically signing below, I acknowledge that I have read and understand this Consent For AI-Assisted Clinical Documentation and voluntarily consent to approved AI-assisted transcription, ambient documentation, or clinical documentation technology during my healthcare encounters.
Consent For Laboratory Blood Draw And Specimen Collection
This consent authorizes The Neighborhood Clinic and its qualified clinical personnel to collect blood or other specimens when ordered or determined to be medically appropriate as part of your healthcare.
Purpose Of Laboratory Testing
Laboratory testing may assist with screening, diagnosis, treatment, medication management, monitoring, preventive care, or other clinically appropriate purposes. Specimens may include blood, urine, swabs, or other appropriate biological samples.
Blood Draw Procedure And Risks
Blood collection generally involves inserting a sterile needle into a vein to obtain one or more samples. More than one attempt may occasionally be necessary.
Possible effects include temporary pain or tenderness, bruising, bleeding, swelling, hematoma, dizziness, nausea, fainting, difficulty obtaining a specimen, infection, or uncommon nerve irritation or injury.
Information I Should Provide
I agree to inform staff about fainting, difficult draws, bleeding disorders, anticoagulants, significant prior reactions, allergies to adhesives or antiseptics, and other conditions that may affect safe specimen collection.
Processing, Results And Outside Billing
Specimens may be processed on-site or sent to an outside laboratory. A specimen may occasionally need to be recollected if it is insufficient or unsuitable.
Outside laboratories may bill independently. Coverage depends on insurance benefits, medical necessity, network participation, deductible, copayment, coinsurance, and other plan requirements.
Right To Ask Questions Or Refuse
I may ask questions or refuse specimen collection before the procedure. Refusal may limit the provider's ability to evaluate, diagnose, monitor, or treat my condition, and some medications or treatments may require laboratory monitoring.
Acknowledgment And Consent
By electronically signing below, I acknowledge that I have read and understand this Consent For Laboratory Blood Draw And Specimen Collection and voluntarily authorize medically appropriate blood draws and specimen collection.
Consent For Electronic Communications
The Neighborhood Clinic uses electronic communication methods to communicate with patients regarding healthcare, appointments, treatment, and administrative matters.
Methods And Types Of Communication
I authorize The Neighborhood Clinic and its authorized representatives to communicate with me using the contact information I provide through text messages, email, telephone calls, voicemail, patient portal, automated reminders, and other appropriate electronic methods.
Communications may include appointments, registration, results, medications, refills, referrals, prior authorizations, follow-up reminders, preventive care, forms, billing, insurance, portal notifications, and general healthcare instructions.
Privacy And Security Risks
I understand that standard text, email, and voicemail may not be completely secure or encrypted and that another person with access to my device or account could see or hear communications.
The Neighborhood Clinic will take reasonable measures to protect privacy but cannot guarantee absolute security of standard electronic communication methods.
Contact Information And Shared Accounts
I am responsible for providing accurate and current contact information and notifying the clinic of changes.
If I provide a shared telephone number, email account, or device, I understand that another person may have access to communications.
Response Times And Emergencies
Electronic communications are not continuously monitored and may not receive an immediate response. They should never be used for a medical emergency.
If I am experiencing a medical emergency or potentially life-threatening symptoms, I should call 911 or go to the nearest emergency department.
Communication Preferences
I may request changes to communication preferences or withdraw consent for certain optional electronic communications. Certain communications may still be sent when permitted or required by law or reasonably necessary for treatment, payment, healthcare operations, or patient safety.
Acknowledgment And Consent
By electronically signing below, I acknowledge that I have read and understand this Consent For Electronic Communications and authorize The Neighborhood Clinic to communicate with me through appropriate electronic methods using the contact information I have provided.
Derechos Y Responsabilidades Del Paciente
The Neighborhood Clinic se compromete a proporcionar atención médica respetuosa, segura, accesible y de alta calidad. Como paciente, usted tiene derechos relacionados con su atención y responsabilidades que ayudan a mantener un entorno seguro y efectivo.
Sus Derechos
Tiene derecho a recibir atención considerada, respetuosa y compasiva sin discriminación, a ser tratado con dignidad y a recibir atención en un entorno razonablemente seguro.
Tiene derecho a participar en decisiones, recibir información comprensible, hacer preguntas, aceptar o rechazar tratamiento cuando corresponda, tener privacidad y confidencialidad, solicitar acceso a su información, recibir apoyo de comunicación y accesibilidad, conocer a su equipo de atención y recibir información sobre costos.
Tiene derecho a expresar inquietudes o presentar quejas sin temor a represalias.
Sus Responsabilidades
Es responsable de proporcionar información completa y precisa sobre su salud, medicamentos, alergias, seguro y contacto, y de informar cambios importantes.
Es responsable de hacer preguntas cuando no comprenda su atención, participar en planes de tratamiento acordados, asistir a sus citas, notificar cancelaciones y cumplir con las responsabilidades financieras aplicables.
Es responsable de tratar con cortesía y respeto al personal, proveedores, pacientes y visitantes.
Seguridad Y Privacidad
No se permite comportamiento amenazante, abusivo, discriminatorio, acosador, sexualmente inapropiado, intimidante, violento o disruptivo.
Se espera que respete la privacidad de otros pacientes y no grabe ni fotografíe a otros pacientes o actividades clínicas privadas sin autorización.
Atención De Emergencia
The Neighborhood Clinic proporciona servicios ambulatorios y no sustituye a un departamento de emergencias. Si tiene una emergencia médica o peligro inmediato, llame al 911 o acuda al departamento de emergencias más cercano.
Reconocimiento
Al firmar electrónicamente a continuación, confirmo que he recibido, leído y comprendido los Derechos Y Responsabilidades Del Paciente de The Neighborhood Clinic y que he tenido la oportunidad de hacer preguntas.