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ADVANCED PSYCHIATRIC GROUPA P G R E S E A R C H , L L C .

Morteza Nadjafi, MD

Deborah L. Amdur, MD

William R. Jeter, MD

Gerald J. Balsam, MD

Laurie Harden, MD

Susanna Chyu, DO

Felicia Turner, ARNP, PMHNP-BC

Ines “Maria” Viloria, ARNP, PMHNP-BC

Jessie Mayne, ARNP-PMHNP

Giselle M. Bolt, ARNP

Sasha Griffin, CPNP-PMHS

Frank Bodenmiller, MS, LMHC

Vicky Quintanilla, LCSW-CAP

M A I N O F F I C E736 N Magnolia Ave . Orlando FL . 32803

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w w w . a p g h e a l t h . c o mA P G R E S E A R C H , L L C . 721 N Magnolia Ave . Orlando FL . 32803

ADVANCED PSYCHIATRIC GROUPA P G R E S E A R C H , L L C .

ADULTDoctor | ARNP | Counselor

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ADULT INFOA D U L T P A T I E N T I N F O R M A T I O N S H E E T

PATIENT NAME:

PATIENT DOB:

ADDRESS:

SOCIAL SECURITY #:

GENDER:

MARITAL STATUS:

______________________ ______________________ _____

_______________ _____

_____________________________________________________

_____________________________________________________

______________________

□ M □ F □ Transgender

□ Single □ Married □ Widowed □ Divorced □ Separated

CELL:

HOME:

WORK + EXT:

EMPLOYER:

OCCUPATION:

STATUS:

______________________

______________________

______________________

______________________

______________________

□ FULL TIME

□ PART TIME

__________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________

PLACE OF EMPLOYMENT:NAME OF PRIMARY INSURANCE:

INSURANCE PHONE #:POLICY/MEMBER ID #:

GROUP #: AUTHORIZATION #:

LAST FIRST M.I.

AGE

__________________________________________ ______________________ __________________________________________ __________________________________________

__________________________________________ ______________________ __________________________________________ ______________________

SPOUSE’S NAME:SPOUSE’S CONTACT PHONE:

SPOUSE’S EMPLOYER:SPOUSE’S OCCUPATION:

PERSON RESPONSIBLE FOR ACCT:RELATIONSHIP TO PATIENT:

ADDRESS IF DIFFERENT:CONTACT PHONE:

How were you referred to this office?__________________________________

Have you been a patient here before?□ Y □ N _______________________

Name & Phone # of closest relative/friend not living with you: __________________

_______________________________________________ ____________________

NAME OF POLICY HOLDER:POLICY HOLDER SSN#:

DOB:GENDER:

__________________________ □ M □ F □ Transgender

CITY, STATE, & ZIPCODE

MEDICARE PATIENTS ONLY**We Do Not Bill Secondary Insurance**

Please make sure you have set up the cross over so that claims can be paid, otherwise it will be the patient’s responsibility.

________________________________________ ________________________________________ ________________________________________ ________________________________________

NAME OF SECONDARY INSURANCE:INSURANCE PHONE #:

ID #:GROUP #:

EMERGENCY CONTACT:PHONE:

RELATIONSHIP TO PATIENT:

_____________________________ _____________________________ _____________________________

WHAT MEDICATIONS ARE YOU CURRENTLY TAKING?________________________________________________________________________________________________________ Pharmacy Name: ________________ Phone: ______________

PLEASE CONTINUE TO PAGE 2

IF YOU ARE UNABLE TO KEEP YOUR APPOINTMENT:KINDLY GIVE **48 HOURS** NOTICE

OTHERWISE, A CHARGE MAY BE MADE FOR THE TIME RESERVED

2

Please remember that insurance is considered a possible source of reimbursement for the fees you pay to the

Doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and

others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or

any other balance not paid for by your insurance company. If the insurance company doesn’t pay within 60

days the patient is responsible for any balance due.

I understand that if my insurer or the company which manages my mental health benefits requires reports from

my therapist, these reports will l ikely include a treatment plan and periodic updates of the treatment plan.

The purpose of these reports is to monitor progress, assure quality and to insure appropriate util ization of

services. These reports may require verbal and written summaries which include a statement of the problem,

history, diagnosis, a formulation of the problem and the dynamics as well as a plan of treatment. If I am a

member of a PPO / HMO this may require reporting to my primary care physician.

I hereby authorize payment directly to Advanced Psychiatric Group, P. A. of any insurance benefits otherwise

payable to me and all medical and/or surgical benefits, to include major medical benefits to which I am

entitled, including Medicare, private insurance and other health plans. Any non-assignable benefits are to be

made payable jointly to the above named group and myself. I also give the above named group authorization

to file any and all claims on my behalf to the insurance commissioner regarding my insurance company.

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be

considered as valid as an original. I understand that I am financially responsible for all charges whether or not

paid by said insurance. I hereby authorize assignee to release all information necessary to secure payment.

I intend to pay medical expenses as follows (check one or more):

□ CASH/CHECK

□ AMEX/DISC/MC/VISA

□ MEDICARE

□ INSURANCE

In the unfortunate event that this account is assigned to any attorney for collection and/or suit, the prevailing

party shall be entitled to any and all attorney’s fees and costs of collection. Also, an additional fee of 40% of

the amount owed will be added for collection charges.

IN THE EVENT THAT I CHOOSE TO DISCONTINUE TREATMENT AND I DO NOT FOLLOW UP WITH MY MEDICAL

PROVIDER IN 6 MONTHS OR LONGER, THEN I UNDERSTAND I AM AUTOMATICALLY DISCHARGED AS A PATIENT

FROM THIS PRACTICE.

I certify that all information on these two pages are true. I have read and understand and agree to the above.

SIGNED: ____________________________________ DATE: _____________

_________________________________

_________________________________

_________________

_________________

SIGNATURE

RESPONSIBLE PARTY

DATE

DATE

3

HEALTH HISTORYH E A L T H H I S T O R Y

___________________________________________________

_________ ______________________ □ M □ F □ Transgender

___________________________________________________

** CONFIDENTIAL **

__________________________

__________________________

SYMPTOMS / Select symptoms you have or have had in the past year

GENERAL

□ Chills□ Depression□ Dizziness□ Fainting□ Fever□ Forgetfulness□ Headache□ Loss of sleep□ Loss of weight□ Nervousness□ Numbness□ Sweats

MUSCLE/JOINT/BONE

Pain, weakness, numbness in:

□ Arms □ Hips□ Back □ Legs□ Feet □ Neck□ Hands □ Shoulders□ Numbness □ Sweats

GASTROINTESTINAL

□ Appetite poor□ Bloating□ Bowel changes □ Constipation□ Diarrhea□ Excessive hunger□ Excessive thirst□ Gas□ Hemorrhoids□ Indigestion□ Nausea□ Rectal bleeding□ Stomach pain□ Vomiting□ Vomiting blood

GENITOURINARY

□ Blood in urine□ Frequent urination□ Lack of bladder control□ Painful urination

CARDIOVASCULAR

□ Chest pain□ High blood pressure□ Irregular heart beat□ Low blood pressure□ Poor circulation□ Rapid heart beat□ Swelling of ankles□ Varicose veins

EYE, EAR, NOSE, THROAT

□ Bleeding gums□ Blurred vision□ Crossed eyes□ Difficulty swallowing□ Double vision□ Earache□ Ear discharge□ Hay fever□ Hoarseness□ Loss of hearing□ Nosebleeds□ Persistent cough□ Ringing in ears□ Sinus problems□ Vision - Flashes□ Vision - Halos

SKIN

□ Bruise easily□ Hives□ Itching□ Change in moles□ Rash□ Scars□ Sore that won’t heal

MEN only

□ Breast lump□ Erection difficulties□ Lump in testicles□ Penis discharge□ Sore on penis□ Other

WOMEN only

□ Abnormal Pap Smear□ Bleeding between periods□ Breast lump□ Extreme menstrual pain□ Hot flashes□ Nipple discharge□ Painful intercourse□ Vaginal discharge□ Other

_________________________

_________________________

_________________________

_________________________

_________________________

CONDITIONS / Select conditions you have or have had in the past year

□ AIDS□ Alcoholism□ Anemia□ Anorexia□ Appendicitis□ Arthritis□ Asthma□ Bleeding Disorders□ Breast Lump□ Bronchitis□ Bulimia□ Cancer□ Cataracts

□ Chemical Dependency□ Chicken Pox□ Diabetes□ Emphysema□ Epilepsy□ Glaucoma□ Goiter□ Gonorrhea□ Gout□ Heart Disease□ Hepatitis□ Hernia□ Herpes

□ High Cholesterol□ HIV Positive□ Kidney Disease□ Liver Disease□ Measles□ Migraine Headaches□ Miscarriage□ Mononucleosis□ Multiple Sclerosis□ Mumps□ Pacemaker□ Pneumonia□ Polio

□ Prostate Problem□ Psychiatric Care□ Rheumatic Fever□ Scarlet Fever□ Stroke□ Suicide Attempt□ Thyroid Problems□ Tonsillitis□ Tuberculosis□ Typhoid Fever□ Ulcers□ Vaginal Infections□ Venereal Disease

(NAME)

(AGE) (BIRTHDATE)

(REASON FOR VISIT)

(DATE)

(DATE OF LAST PHYSICAL EXAMINATION)

(DATE OF LAST MENSTRUAL PERIOD)

(DATE OF LAST PAP SMEAR)

(HAVE YOU HAD A MAMMOGRAM)

(ARE YOU PREGNANT)

(NUMBER OF CHILDREN)

(GENDER)

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HEALTH HISTORYH E A L T H H I S T O R Y C O N T .

** ALL INFORMATION IS STRICTLY CONFIDENTIAL **

FAMILY HISTORY / Fill in health information about your family

Relation Age State of Health

□ Arthritis, Gout □ Asthma, Hay Fever□ Cancer□ Chemical Dependency□ Diabetes□ Heart Disease, Strokes□ High Blood Pressure□ Kidney Disease□ Tuberculosis□ Other

Age at Death

Cause of Death

Father

Mother

Brothers

Sisters

____

____

________________________________

_____________

_____________

________________________________________________________________________________________________________

____

____

________________________________

_________________

_________________

________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Select if your blood relatives had any of the following:

Relationship to you:

HOSPITALIZATIONS

Year Hospital Reasons for hospitalization

______________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________

SERIOUS ILLNESS / INJURIES

and outcome

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Description Date Outcome

______________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________

____________________________________________________________________________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________

Have you ever had a blood transfusion? □ Y □ NIf yes, approximate dates: ______________________________

PREGNANCY HISTORY HEALTH HABITS OCCUPATIONAL CONCERNS

Birth Year Sex Complications (if any)

________________ ________ ________ ________ ________

___ ___ ___ ___ ___ ___

____________________ ____________________ ____________________ ____________________ ____________________ ____________________

□ Caffeine □ Tobacco□ Drugs□ Alcohol□ Other□ ___________

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

_________________________________

_________________________________

________________

________________

SIGNATURE

REVIEWED BY

DATE

DATE

□ Stress □ Hazardous Substances□ Heavy Lifting□ Other

Occupation: _______________________

________________________________________________

MEDICATIONS / List any you are currently taking______________________________________________________________________________________________________Pharmacy Name: ________________ Phone: _____________

ALLERGIES / To medications or substances_________________________________________________________________________________________________________________________________________________________

Select substances you use and describe how much you use

____________________ ____________________ ____________________ ____________________ ____________________ ____________________

Select any of the options that your work exposes you to

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T R E A T M E N T C O N S E N T F O R M

Explanation of Consent Form

This treatment consent form covers all procedures that are not of a nature to require a special consent, and it provides protection for the procedures performed by the professional staff of Advanced Psychiatric Group. This form documents that the patient has consented to treatment at Advanced Psychiatric Group, including but not limited to medicine management, psychotherapy and counseling. This allows the professional staff at Advanced Psychiatric Group to provide services to you.

This form provides evidence that no guarantee is made by any professional at Advanced Psychiatric Group concerning the outcome of treatment. There is no guarantee that treatment will be successful. This form also provides evidence that consent is given only after a full explanation has been provided by the staff at Advanced Psychiatric Group. If you have any questions concerning this or any other matters, it is your responsibility to ask your psychiatrist or therapist. By signing this form, you acknowledge that you understand your consent to treatment as explained in this form.

Consent to Treatment

I _________________________________ , for __________________________________do hereby voluntarily consent to care and

treatment by Advanced Psychiatric Group, assistants and/or designees. I am aware that the practice of medicine, psychiatry, clinical psychology, and clinical social work is not an exact science and I acknowledge that no guarantees have been made as to the result of evaluation or treatment.

I am aware that I am an active participant in the counseling process and that I share responsibility for my treatment. My responsibilities in treatment include informing the psychiatrist or therapist of any information that may be relevant to the problems or conditions being treated, assisting in setting goals for treatment, following therapeutic advice to the best of my ability, and ending in treatment in a responsible way.

If I am consenting to treatment for another person, I certify that I am legally responsible for that person and am entitled to consent to treatment for them.

This form has been fully explained to me and I certify that I understand its contents. I also understand that it is my sole responsibility to ask any questions or obtain any clarification necessary to my understanding this form fully.

(PRINT YOUR NAME) (PRINT THE CLIENT’S NAME)

_________________________________

_________________________________

_________________

_________________

SIGNATURE

WITNESS

DATE

DATE

NAME:

SOCIAL SECURITY NUMBER:

DATE:

______________________________

______________________________

______________________________

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A P G r e s e a r c h , l l c .

736 N MAGNOLIA AVE . ORLANDO FL . 32803

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H I P A A

Consent to use and disclose your health information

This form is an agreement between you, ___________________________ (Patient’s name/Parent or Guardian name if Minor) and Advanced Psychiatric Group, P.A. If you wish to include the name(s) of an individual(s) (Ex: spouse, child, relative, other) to whom we can discuss your Private Health Information (PHI), please write their name here:_______________________________.

When we examine, diagnose, treat, or refer you we will be collecting what the law calls PHI about you. We need to use this information here to decide on what treatment is best for you and to provide treatment to you. We also need it to arrange payment for your treatment.

By signing this form you are agreeing to let us use your information here and send it to others when the law requires us to use or share it. The Notice of Privacy Practices explains more in detail your rights and how we can use and share your information. Please read this before signing this Consent form. You can retrieve a copy of the NPP from the receptionist.

If you do not sign this consent form agreeing to what is in our Notice of Privacy Practices we cannot treat you.

If we want to use or disclose (send, share, release) your information for any other purposes we will discuss this with you and ask you to sign an Authorization form to allow this. In the future we may change how we use and share you information and so may change out NPP. If we do change it, you can get a copy from our office by calling us at 407-423-7149, or from our privacy officer.

If you are concerned about some of your information, you have the right to ask us to not use or share some of your information for treatment, payment or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to agree to these limitations. However, if we do agree, we promise to comply with your wishes.

After you have signed this consent, you have the right to revoke it (by writing a letter telling us you no longer consent) and we will comply with your wishes about using or sharing your information from that time on but we may already have used or shared some of your information and cannot change that.

Date of NPP _______________________ Copy given to the client / parent / personal represenative.

_________________________________

_________________________________

_________________________________

_________________

_________________

CLIENT SIGNATURE / PERSONAL REPRESENTATIVE

CLIENT NAME / PERSONAL REPRESENTATIVE

DATE

RELATIONSHIP TO CLIENT

Description of personsal representative’s authority

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A P G R E S E A R C H , L L C .

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F I N A N C I A L P O L I C Y

As part of an effort to provide the best possible medical care to you, we would like to explain our financial policies in advance.

1) Your health insurance is a contract between you, your insurance company, and your employer. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, or coordination of benefits. Our professional services are rendered to you, not the insurance company. Therefore, payment for services ultimately is your responsibility.

If you have a referral based on HMO or PPO insurance plan, it is your responsibility to obtain initial referrals or authorizations. Not all therapy services or psychiatric conditions are part of a covered benefit by all insurance plans. Please understand that if your insurance does not pay for a particular service, you will be responsible for the payment in full. It is your responsibility to understand your plan benefits. We only file with your primary insurance. It is the patient’s responsibility to file any additional insurance.

Please inform the receptionist of ANY changes in your benefits or changes in the company that insures you PRIOR to your appointment. If by your failure to provide us with current information, your insurance company subsequently denies us payment, you may be held financially responsible for those unpaid charges.

Your deductible and co-payment are due at the time of your visit. For your convenience we accept cash, checks, American Express, Discover, Visa, and Master Card. All returned checks are subject to a returned check fee of $35.00. There will be a $10.00 fee for sending you a bill for any unpaid balance.

2) Completion of forms or requests for letters regarding such matters as employment, disability, education or legal issues will be subject to a minimum charge of $50.00 depending on the length of the letter/paperwork. We ask that you give us at least 5-7 working days advance notice so we have time to fulfill your request. We will not provide these additional services at the initial consultation.

3) We ask that you give us a 48 business hours prior notice of cancellation. You may be liable for the full cost of the time that is specifically set aside for your appointment if you do not. We cannot charge your insurance company for the no show or late cancellation therefore you may be charged the full office visit fee for the time reserved.

4) ALL prescription refills require 48 business hours notice and a consultation with the physician within the previous 90 days. If your prescription has run out as you did not keep a scheduled appointment, there will be a $35.00 charge for writing a renewal. No prescriptions renewal will be called in during the weekends.

5) Our providers will be happy to answer short questions over the phone or take a phone call for an emergency or medication issues. However, it is best to discuss more involved issues during an appointment. We will make every effort to accommodate you as soon as possible within the constraints of our schedule. Telephone consults of more than 5 minutes may be charged at our regular fee.

I have read and understand the Financial Policy above.

ACKNOWLEDGEMENT

_______________________________ ________________

_______________________________ ________________

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A P G R e s e a r c h , L L C .

736 N MAGNOLIA AVE . ORLANDO FL . 32803

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CLIENT NAME DATE

CLIENT SIGNATURE / PATIENT / GUARDIAN IF MINOR DATE

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D I S A B I L I T Y D I S C L A I M E R

Our office does not specialize in disability claims, therefore we advise you of this upon scheduling. We cannot guarantee that these additional services will be provided at the initial consultation or upon request.

I understand that Advanced Psychiatric Group, P.A. does not specialize in disability claims. I understand that I am a new patient and have elected to be seen for treatment only. Providers in this office will not complete FMLA paperwork, disability forms, or provide documentation to support medical leave from work for new patients.

I have read and understand the Disability Disclaimer above.

ACKNOWLEDGEMENT

_______________________________ ________________

_______________________________ ________________

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A P G R e s e a r c h , L L C .

736 N MAGNOLIA AVE . ORLANDO FL . 32803

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CLIENT NAME DATE

CLIENT SIGNATURE / PATIENT / GUARDIAN IF MINOR DATE

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M E D I C A T I O N S I D E E F F E C T S

High potential for abuse or dependence, exacerbate symptoms of pre- existing/new onset psychosis/ticks/glaucoma and/or bi-polar, aggression, suppression of growth in children, seizures, blurred vision, palpitations, arrhythmia, restlessness, dyskinesia, tremors, dry mouth, anorexia, and decreased libido.

Drowsiness, ataxia, risk of falls, confusion, respiratory depression, hallucinations, insomnia, shortness of breath, hair loss, rash, withdrawal seizures, weight loss or gain, anemia, somnolence, flushing, upset stomach, dry mouth, and increased congenital malformations. Risk for addiction.

Increased risk of suicidality, increased risk of congenital malformations, hypotension, arrhythmia, heart block, stroke, impaired gait, dizziness, urinary retention, rash, bone marrow suppression, nausea, vomiting, testicular swelling, gynecomastia, weight gain or loss, headache, hair loss and parotid swelling.

Increased risk of suicidality, weight gain or loss, tremors, headache, decreased libido, nausea, increased blood pressure, increased risk of seizures, and congenital malformations.

Increased risk of mortality in elderly patients with dementia related psychosis 1.7 times placebo possibly secondary to heart failure, sudden death or pneumonia. Increased risk of diabetes, high triglycerides, weight gain, tardive dyskinesia, rigidity, tremor, NMS or restlessness, and/or decrease in sexual libido. Torsade de Pointes Arrhythmia and sudden death.

Increased risk of mortality in elderly patients with dementia related psychosis 1.7 times placebo possibly secondary to heart failure, sudden death or pneumonia. Increased risk of diabetes, high triglycerides, weight gain, tardive dyskinesia, rigidity, tremor, NMS or restlessness, and/or decrease in sexual libido. Torsade de Pointes Arrhythmia, seizure - decrease of blood elements and sudden death.

Hepatotoxicity resulting in hepatic failure, elevated liver enzymes, hepatitis, pancreatitis, congenital malformations, anemia, renal disease, hair loss, elevated liver enzymes, weight gain or loss, tremors, fatal rash, somnolence, diabetes insipidus and bleeding.

Increased risk of suicidality, weight gain or loss, tremors, headache, decreased libido, nausea, increased risk of seizures, and congenital malformations.

By signing below, I acknowledge that the most common side effects associated with medication(s) have been explained and I understand that other possible side effects from my medication(s) may occur. I also agree to follow all recommendations of my psychiatrist.

_______________________________ ________________

_______________________________ ________________ _______________________________ ________________

These are some of the known but not all of the side effects of these medications as listed in the Physician’s Desk Reference.

Adderall, Dexedrine, Vyvanse & Ritalin

Ativan, Klonopin, Librium, Serax, Tranxene, Valium,

Buspar, Atarax, Xanax

Anafranil, Asendin, Elavil, Despiramine, Norpramin,

Sinequan, Surmontil, Tofranil & Vivactil

Wellbutrin, Effexor, Remeron, Serazone, Cymbalta, Trazadone, & Pristiq

Haldol, Loxitane, Mellaril, Moban, Navane, Prolixin,

Serentil, Stelazine, Thorazine & Trilafon

Abilify, Clozaeil, Risperdal, Seroquel, Geodon, Invega, Zyprexa, Latuda, Saphris &

Fanapt

Depakene, Depakote, Lithium, Lamictal, Neurontin, Tegretol, Triliptal & Topamax

Celexa, Lexapro, Luvox, Paxil, Prozac, Zoloft

ADHD

Anti-Anxiety Agents

Tricyclic Anti-Depressants

Other Anti-Depressants

TypicalAntipsychotics

AtypicalAntipsychotics

MoodStabilizers

SSRI Anti-Depressant

PATIENT NAME: _________________________________________ DATE OF BIRTH: ___________________

PATIENT REPRESENTATIVE RELATIONSHIP TO PATIENT

WITNESS DATE

SIGNATURE (PATIENT OR PATIENT REPRESENTATIVE) DATE

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A P G R e s e a r c h , L L C .

736 N MAGNOLIA AVE . ORLANDO FL . 32803

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O F F I C E P O L I C Y C H E C K L I S T

1. Please make sure to get your prescriptions at the time of the your appointment. Any refill request prior to or after an appointment will be subject to a refill fee of $35.

2. Please give us 48 hours (2 business days) to cancel or reschedule an appointment. Otherwise it will be subject to a $50.00 fee or a full office visit fee. This also applies if you fail to show up to a scheduled appointment.

3. Please call us at least 48 hours (2 business days) prior to your appointment if your insurance has changed. Not doing so can delay the verification process and you may be subject to the full office visit fee.

4. Phone consultations should be reserved for emergencies only. This is not billable to insurance.

5. Prior authorizations are needed for any medication, please have your health insurance fax us the “Prior Authorization” forms to fill out and fax back to the insurance (Prior Authorizations are only handled by fax). If we do this for you there will be a $25 fee.

6. If you need a form completed (e.g. medical leave, school), please call the office and set up a separate appointment for that. We need at least a 5-7 working days advanced notice to prepare the paperwork. There will be a minimum charge of $50 for each letter or form completed.

I have read and understand the Office Policy Checklist above.

ACKNOWLEDGEMENT

_______________________________ ________________SIGNATURE DATE

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A P G r e s e a r c h , l l c .

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F R E Q U E N T LY A S K E D Q U E S T I O N S

What do I do if my medication is not covered by my insurance company?Ask, your pharmacy if you need a Prior Authorization. If they say yes, please call your insurance company and have them fax us the Prior Authorization form to 407-422-0470. Once your provider completes the form we fax it back to your insurance company then we wait to see if they approve or deny the medication.

What if my pharmacy states that my medication needs prior authorization?Please call your insurance company and have them fax us the Prior Authorization form to 407-422-0470. Once your provider completes the form we fax it back to your insurance company then we wait to see if they approve or deny the medication.

My pharmacy states they sent the Prior Authorization to my doctorYour pharmacy only sends the doctor’s office notification that the medication needs Prior Authorization. The pharmacy does not send the forms to our office. Please call your insurance company and have them fax us the Prior Authorization form to 407-422-0470. Once your provider completes the form we fax it back to your insurance company then we wait to see if they approve or deny the medication.

How long does this process take?This process can normally take 3-5 business days. Your insurance company may tell you 7-10 days.

What if my authorization is expiring and I need a new one (re-authorization)?Please let your provider’s assistant know at least a week or more in advance (as soon as possible is best). This way she can help you begin this process.

What is considered an urgent request?Urgent requests are reserved for antipsychotics, antidepressants, mood stabilizers and anti anxiety medications. If you have any questions about these classes of medications please do not hesitate to ask your provider’s assistant.

My insurance is stating that my doctor’s office needs to call my insurance company for prior authorization and they have given me an 800-xxx-xxxx phone numberWe do not do Prior Authorizations for medications over the phone. Please have your insurance company fax the form to our office for your doctor to complete.

What does it mean if the medication prescribed is not on my insurance formulary?First, call your insurance company or visit their website and ask what medications in that “class” are covered by your plan. Obtain a list of covered medicines and fax it to our office at 407-422-0470. Call the office and speak directly to your provider’s assistant to inquire on how to proceed.

My medication is covered by my insurance but is still too expensiveFirst, call your insurance company or visit their website and ask what medications in that “class” are covered by your plan. Obtain a list of covered medicines and fax it to our office at 407-422-0470. Call the office and speak directly to your provider’s assistant to inquire on how to proceed.

How will I know if my Prior Authorization is approved or denied?Your insurance company will notify your pharmacy, provider’s office, and will send you a letter with their determination. You may also contact your insurance company directly.

What if I need an appeal?The providers do not complete appeals over the telephone. However, for certain medications they may complete a written appeal or complete a form required by your insurance. Please contact your provider’s assistant for further information.

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