SAVE TIME BEFORE COMING IN

Simply choose a form below, print it out, fill it out & bring it to your next appointment.

Step 1 - Authorization to Release Information for Treatment, Billing, or Health Care Operations

Step 2 - Clinic Policy

Step 3 - Credit Card Policy

Step 4 - Notice of Privacy Practices and Policies

Step 5 - Intake Form

Step 1

Authorization to Release Information for Treatment, Billing, or Health Care Operations

You are not required to give this authorization. However, claim charges denied due to a failure to provide requested documents (due to a lack of authorization) will be the responsibility of the patient. I understand that I have the right to review the Privacy Notification prior to signing this consent.

I understand that Dr. Marok, MD reserves the right to change his notices and practices, and I will be given new notification if this occurs. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations, and the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

Records may be needed in order to process a claim for medical services. I authorize Dr. Marok, MD to release information needed for billing purposes to entities that may provide services pertaining to my physician visit, such as reference laboratories. I understand that by signing below, I am authorizing the release of all or part of my medical record for the purpose of my treatment, billing, or pertinent health care operations. This release may include records containing information regarding the diagnosis and/or treatment of HIV or AIDS, mental illness, and/or drug and/or alcohol addiction or abuse to any person or corporation which is or may be liable under contract for all or part of the medical charges, including but not limited to, Medicare, Medicaid, or other private or public health insurance programs, reviewing agencies, worker’s compensation carriers, welfare agencies or patient’s employer.

Step 2

Clinic Policy

Office Services:

Documentation fee: Phone Consultation: Disability Forms: Missed appointment:

$35 for first page & $10 for each additional page Billed on hourly rate of $300/hr. $125 + $10/per page

Family Psychiatry
Dr. Marok, MD

Family Psychiatry is committed to meeting the needs of individuals and families. We are based on the principles of health and wellness and believe that patients mental well-being is of the upmost importance. Our aim to treat every patient with respect and confidentiality, we maintain and adhere to our own privacy standards. As a condition of treatment in our clinic patients agree to maintain treatment confidentiality.

Insurance:
We are a preferred provider for Premera, Blue Cross Blue Shield and Regence of Washington and are out-of- network for other plans. We bill and handle payments for Premera and Regence electronically. We are unable to offer single case agreements. We ask patients to verify individual plans benefits and coverage before their scheduled appointment. We ask that patients provide the office with all insurance details prior to an office visit and a have their health insurance card available at the time of the office visit. Claims that cannot be processed due to lack of coverage or missing information will be the patient’s responsibility for the balance due. As part of the Clinic Policy, a credit card (HSA/FSA/debit/credit card) must be held on file for co-payments/patient responsibilities for patient accounts, as Billing electronically processes payments. We do not send out statements, but patients will receive an Explanation of Benefits from their health insurance company.

Self-Pay/Out-of-network:
Patients that are self-pay or out-of-network should refer to the individual fee structure below. We do not participate in Medicaid or Medicare plans and thus reimbursement is based on a fee for service basis for which patients agree not to process claims through Medicare or Medicaid. Patients should refer to individual plan benefits for questions regarding coverage. Self-pay patients will be sent an electronic statement for confirmation of payment. Payment can be made via check, cash or credit card.

Psychiatric Evaluation Adult/Child (50 min) $375 Follow-up Visit (30 min) $195 Therapy & Medication Management Visit (50 min) $285

$175/ if not rescheduled prior to 48 hours
Patient agrees to pay any account balance in full upon receipt of invoice and all account balances

including late fees must be paid within 14 days unless otherwise arranged with the clinic.

Please remit all payments to:

Family Psychiatry
22525 SE 64th Place Bldg. H, Suite 228 Issaquah, WA 98027 (425) 606-0230

Hours:
The clinic is open Monday through Thursday from 9:00-5:00pm. During business hours, we are happy to schedule appointments and answer questions. Please leave a message with the front desk or contact us via email for routine non-emergent situations and calls/e-mails will be returned within two business days. The clinic is closed after hours and on weekends. For Psychiatric emergencies, including thoughts of self-harm, adverse reaction to medication please call 911 and proceed to the nearest emergency room.

As a condition of treatment in our clinic you agree to adhere to the clinic policies as set forth in this document of Family Psychiatry.

Step 4

Notice of Privacy Practices and Policies

• This document describes as required by federal legislation how health care information may be used and disclosed and how you can obtain access to this information. This information applies to all electronic and paper records kept by Family Psychiatry and Dr. Marok, MD and other office personnel involved in clinical care including outside entities.

  DISCLOSURE OF INFORMATION INCLUDES:

• The following categories describe ways that I use and share your confidential information. Confidential information includes Protected Health Information (“PHI” - information that could be used to identify you). Not every use or disclosure in a category is listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

  ROUTINE SITUATIONS

• For Treatment I may use information about you to provide you with medical treatment or services. Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment is when I consult with another health care provider, such as your primary care physician.

• For Payment I may use and disclose information about you so that the treatment and services you receive at the practice may be billed and payment may be collected from you, an insurance company or a third party – including a collection agency if necessary. For example, I may give your health plan information about services you received at the practice so your health plan will pay my practice or reimburse you for the services. I may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

• For Health Care Operations I may use and share information about you for administrative functions necessary to run my practice and promote quality care. For example, I may use your information or combine it with other patient information to review the effectiveness of my treatment and services, to evaluate my performance in caring for you, or to make decisions about additional services my practice should offer. Wherever it is practical, I may remove information that identifies you.

• I may share information with business associates who provide services necessary to run my practice, such as transcription companies or billing services. I will contractually bind these third parties to protect your information as I would. Also, I may permit your health plan or other providers to review records that contain information about you to assist them in improving the quality of service provided to you.

• Communicating with You and Others Involved in Your Care my practice may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. In certain situations, I may share information about you with a friend or family member of yours who is involved in your care or payment for your care unless you have requested that such disclosures not occur and I have agreed. Information disclosed will be directly relevant to such

  person’s involvement. Dr. Marok, MD 22525 SE 64th Place, Building H, Suite 228, Issaquah, WA 98027 with your care or payment related to your care. Whenever possible, this person will be identified by you. However, in emergencies or other situations in which you are unable to indicate your preference, I may need to share information about you with other individuals or organizations to coordinate your care or notify your family.

  SPECIAL SITUATIONS

• As Required By Law: I will disclose information about you when required to do so by federal, state or local law. For example, I may release information about you in response to a valid subpoena or for communicable disease reporting.

• Health Oversight Activities: I may disclose information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

• For Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that you have received within my practices and the records thereof, such information may be privileged under state law, and I will not release information without the written authorization of you or your legal representative, or in instance of issuance of a subpoena requiring provision of such information of which you have been properly notified and in response to which you have not opposed the subpoena within the legally specified format and time frame, or in the instance of issuance of a court order compelling me to provide PHI. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

• To Avert Serious Threat to Health or Safety: I may disclose your confidential mental health information to any person without authorization if I believe reasonably that disclosure will avoid or minimize imminent danger to your health or safety, or the health or safety of any other individual. These disclosures may be to law enforcement officials to respond to a violent crime, or to protect the target of a violent crime. For example, threat of harming another individual may be reported to appropriate authorities.

• Worker’s Compensation: If you file a worker's compensation claim, with certain exceptions, I must make available, at any stage of the proceedings, all PHI information in my possession that is relevant to that particular injury in the opinion of the Washington Department of Labor and Industries, to your employer, your representative, and the Department of Labor and Industries upon request.
  Public Health Risks: I may disclose information about you for public health activities. These activities generally include, but are not

limited to, the following:

Family Psychiatry

• To prevent or control disease, injury or disability, report child abuse or neglect, adult and domestic abuse. Reactions to medications or problems with products. Notify people of recalls of products they may be using. Notify a person who may have been exposed to a disease or may be at risk for contracting or spreading disease or condition. Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. Law Enforcement: I may release information about you if asked to do so by a law enforcement th

• Official: Dr. Marok, MD 22525 SE 64 Place, Building H, Suite 228, Issaquah, WA 98027

• In response to a court order, subpoena, warrant, summons or similar process, identify or locate a suspect, fugitive, material witness, missing

  person. If you are suspected to be a victim of a crime, generally with your permission. About a death we believe may be the result of

  criminal conduct. About criminal conduct at the hospital

• In emergency circumstances, to report a crime; the location of the crime or victims; or the identity, description or location of the person

  who committed the crime. DISCLOSURES THAT REQUIRE AUTHORIZATION. Psychotherapy notes are handled separately under HIPAA and have additional protections. Specifically, the regulations state that in most instances a practice must obtain an authorization for any use or disclosure of psychotherapy notes. No authorization is needed to carry out treatment, payment, or health care operations and the uses listed in routine situations. All other circumstances require a valid authorization from you for use and disclosure. Confidential information may be released for payment and health care operations only to health plans and their agents and business associates of the practice. The definition of health plan does not include life insurance companies, automobile insurance companies or workers’ compensation carriers. These are not covered under HIPAA, and if you would like information submitted to one of these companies, an authorization will be required, unless I am otherwise required by state or federal law. Your right as a patient. In addition to provisions by the practice to protect your confidential information, you are entitled to six specific rights as a patient. You have the right to request restrictions on certain uses and disclosures. You have the right to request a restriction or limitation on the use and sharing of information about you for treatment, payment, administrative functions, or with individuals involved in your care. To request restrictions, you must make your request in writing. In your request, you must tell me 1) what information you want to limit; 2) whether you want to limit or use disclosure or both; and 3) to whom you want it to apply. I am not required to agree to your request. If I agree, I will comply with your request unless the information is needed to provide you with emergency treatment. You have the right to receive confidential communications. You have the right request that my staff or I communicate with you in a certain way or at a certain location. For example, you can ask that we only contact you at work or at a post office box. To request confidential communications, you must make your request in writing. Your request must specify how or where you wish to be contacted. I will not ask you the reason for your request. I will seek to accommodate all reasonable requests. You have the right to inspect and obtain copies. You have the right to review and obtain copies of information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes, information compiled in reasonable anticipation of a legal action or proceeding; and confidential information related to certain laboratory tests under CLIA. To inspect and copy information that may be used to make decisions about you, you must submit your request inwriting.

• You may be charged a fee for the costs of copying, mailing or other supplies associated with your request. In the following circumstances I may deny your request to inspect and copy information.

• I have determined, in the exercise of professional judgment, that the access requested is reasonably likely to endanger the life or physical safety of you or another person. The information makes reference to another person (unless the other person is a health care provider) and Ihave determined, in the exercise of professional judgment that the access

• Dr. Marok, MD 22525 SE 64th Place, Building H, Suite 228, Issaquah, WA 98027
  requested reasonably likely to cause substantial harm to the other person; or The request for access is made by your representative and I have determined, in the exercise of professional judgment that the provision of access to your personal representative is reasonably likely to cause substantial harm to you or another person.

• If you are denied access, you may request a review of the denial. The review will be completed by a qualified individual other than myself. I will comply with the outcome of the review. You have the right to amend confidential information. If you feel that the information I have about you is incorrect or incomplete, you may ask me to amend the information. You have the right to request an amendment for as long as the information is kept by or for my practice. To request an amendment, your request and a reason

• that supports your request must be made in writing and submitted to me. I may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, I may deny your request if you ask me to amend information that:

• Was not created by my practice, unless the person or entity that created the information is no longer available tomake the amendment. In such instances I would consider the request. Is not part of the Information kept by or for my practice.

• Is not part of the information which you would be permitted to inspect and copy

• Is accurate and complete. You have the right to receive an accounting of disclosures of confidential information. You may ask to receive an accounting of certain disclosures made about you that were not related to the routine uses listed above. To request this list or accounting of disclosures, you must submit your request in writing tome.

o Your request must state a time period that may not be longer than six years and indicate in what form you want the list (for example on paper or in an electronic file). The first list you request will be free. For additional lists, I may charge you the costs of providing the list. I will notify you of the estimated cost involved and you may choose to withdraw or modify your requests because any costs are incurred. Disclosures do not have to be made when those disclosures are:

Family Psychiatry

• To carry out treatment, payment and health care operations. To individuals of confidential information about them/ As a result of assigned authorization. For the practice’s directory or to persons involved in your care. For national security or intelligence purposes; or To correctional institutions or law enforcement officials You have the right to obtain a paper copy of this Notice upon request. Even if you have requested an electronic copy, I will provide you with a paper copy of this Notice at your request. In addition to your rights as a patient, my practice has duties to protect your confidential information and inform you of changes to protection measures. I am required by law to maintain the privacy of confidential information and provide you with notice of my legal duties and privacy practices with respect to such information. I am required to abide by the terms of this Notice currently in effect. Changes to this Notice: Dr. Marok, MD

  22525 SE 64th Place, Building H, Suite 228, Issaquah, WA 98027

• I reserve the right to revise or change provisions on this notice. I will make the new Notice provisions effective for all confidential information I maintain. I will promptly revise and distribute my Notice whenever there is a change to the uses or disclosures, your rights, and my duties, or other privacy practices stated in this Notice. I will post a note indicating that there are changes to the Notice throughout my practice for six months from the effective date of the change. A copy of the current Notice will be available throughout my practice. The Notice will contain the effective date on the top of first page.

• COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with me or with the Secretary of the Department of Health and Human Services. All complaints must be submitted or verified in writing. You have specific rights under the Privacy Rule. You will not be penalized for filing a complaint.

• OTHER USES OF INFORMATION: Other uses and disclosures of information not covered by this notice or the laws that apply to my practice will be made only with your written permission. If you provide my practice specific permission to use or disclose information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, I will no longer use or disclose information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures I have already made with your permission, and that I am required to retain my records of the care that I provided to you.

• PRIVACY OFFICER: I am the privacy officer for my practice. You may contact me with questions or comments at 425-606-0230 or by

  mail to Dr. Marok, MD 22525 SE 64th Place, Building H, Suite 228, Issaquah, WA 98027

• ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE I am required to provide you with a copy of this Notice and document your

  receipt. Please fill out an Acknowledgement of Receipt of Notice of Privacy after receiving this Notice. (See Below.)

• Dr. Marok, MD 22525 SE 64th Place, Building H, Suite 228, Issaquah, WA 98027

  Acknowledgement of Receipt of Notice of Privacy Practices

• In order to comply with HIPAA standards each practice must get a signed acknowledgement that each direct treatment patient has received its Notice of Privacy Practices or must document a good faith effort to provide the Notice and receive a written acknowledgement of receipt. This will allow practices to use or disclose confidential information (protected health information) for treatment, payment, or health care operations.

• I have received a copy of the Notice of Privacy Practices from:
  Dr. Marok, MD 22525 SE 64th Place, Building H, Suite 228, Issaquah, WA 98027

Credit Card Authorization

Family Psychiatry
Meadow Creek Professional Center 22525 SE 64th Place
Building H, Suite 228 Issaquah, WA 98027
Phone: 425-606-0230 Fax: 425-777-2103

Credit Card Payment Authorization Form
We process payments electronically and your credit card is kept on file for payment. Sign and complete this form to authorize Family Psychiatry to automatically charge your Visa, MasterCard, American Express or Discover Card. By signing this form, you give Family Psychiatry permission to debit your account for the amount due and to keep this credit card on file for you.

 Forms

Save time before coming in.

Simply choose a form below, print it out, fill it out & bring it to your next appointment.

New Patient Intake Packet [PDF]

HIPPA Form

Consent To Treat & Clinic Policies

Intake Form

In order to serve you properly, please complete ALL of the following information and bring it with you to your first visit. You may need to ask family members about the family history. If assistance was required in filling this form out, please indicate on form with name and relationship.

List ALL current prescription medications and how often you take them (if none, write N/A):

Medication Name

Total Daily Dosage

Estimated Start Date

Patient Intake Form

Family Psychiatry

List ALL current prescription medications, mg's and how often you take them (if none, write N/A):

Your Medical History

Height/weight:

Please list any allergies:

Current over-the-counter medications or supplements:

Current medical problems:

Past medical problems, non-psychiatric hospitalization or surgeries:

Have you ever had an EKG? Yes No If yes, when was the EKG?

Results: normal abnormal or unknown ?

For Women Only

Date of last menstrual period:

Are you currently pregnant or do you think you might be pregnant? Yes No

Are you planning to get pregnant in the near future? Yes No

How many times have you been pregnant?

How many live births?

Personal and Family Medical History

You

Family

Which Family Member?

Thyroid Disease

Anemia

Liver Disease

Chronic Fatigue

Patient Intake Form

Family Psychiatry

Personal and Family Medical History

Diabetes

Kidney Disease

Asthma/Respiratory Problems

Stomach or Intestinal Problems

Fibromyalgia

Heart Disease

Epilepsy or Seizures

Chronic Pain

High Cholesterol

High Blood Pressure

Head Trauma

Liver Problems

Other

Any additional personal or family medical history? Yes No If yes, please explain:

Any history of brain injury, being knocked unconscious, or seizures? Yes No If yes, please explain:

Past Psychiatric History

Outpatient Treatment? Yes No If yes, please list (Reason/Date(s) treated/by whom) below:

Psychiatric Hospitalization? Yes No If yes, please list (Reason/ Date(s)/Location) below:

Past Psychiatric Medications

Please list if you have ever taken any of the following medications: Antidepressants, Mood Stabilizers, Antipsychotics, Sedatives, and Hypnotics, ADHD medications, Anti-anxiety medications. If yes, please list:

Patient Intake Form

Family Psychiatry

Family Psychiatric History

Has anyone in your family been diagnosed with or treated for:

Yes

No

Which member?

Bipolar disorder

Schizophrenia

Depression

Post-traumatic Stress

Anxiety

Alcohol Abuse

Other Substance Abuse

Suicide

Anger

Violence

Has any family member been treated with a psychiatric medication? Yes No

If yes, who was treated and what medications and how effective was the treatment?

Substance Use

Have you ever been treated for alcohol or drug use or abuse? Yes No

If yes, for which substances?

If yes, where were you treated and when?

Any history of complicated withdrawal from substances including seizures or delirium tremens (DTs)? If yes, explain.

Patient Intake Form

Family Psychiatry

Are you currently using any alcohol, recreational drugs, or misusing prescription medications? Yes No

Tobacco History

Do you currently use any tobacco products such as cigarettes, cigars, pipes, or chewing tobacco? If yes, how much and how often?

Trauma History

Do you have a history of being abused emotionally, sexually, physically or by neglect? Yes No

Educational History

What is your highest educational level or degree attained?

Occupational History

Are you currently: Working Not working by choice Unemployed Disabled Retired

What is/was your occupation and location of employment?

Have you ever served in the military? Yes No If so, what branch and when?

Honorable discharge? Yes No Other type of discharge

Relationship History and Current Family

Are you currently: Married Divorced Single Widowed Partnered

How long?

If not married, are you currently in a relationship? Yes No If yes, how long?

What is your spouse or significant other’s occupation?

Describe your relationship with your spouse or significant other:

Have you had any prior marriages?

Yes No

If so, how many? How long?

Do you have children?

Yes No

Describe your relationship with your children:

Patient Intake Form

Family Psychiatry

Legal

Have you ever been arrested?

Yes No

Do you have any pending legal problems?

Yes No

Thank you for completing the following information. If there is anything else that you would like the provider to know, please indicate below:

Signature:

Date:

Emergency Contact/Relationship:

Phone Number:

If signed by a patient representative, state relationship to patient: