New Patient Application IMPORTANT INFORMATION - PLEASE READWe are opening selected appointments for a few new patients. Dr Elkin will personally evaluate your application to achieve the best possible fit for the patient. New appointments can take last more than an hour. If you are being referred by another physician please have all requested documents prior to your first appointment. The Release of Information form can be found at www.drelkin.com, under the forms tab. We no longer accept Cigna and United Health Care or their subsidiaries. You may submit the superbill on your own for out of network reimbursement if your health insurance company allows it. We accept Aetna and Blue Cross Blue Shield and Private pay at an hourly rate. NOTE: Your credit card information is securely stored. Our goal is to provide a good fit for both patient and provider. We will contact you within 3 weeks if not sooner after Dr Elkin reviews your application. We look forward to and appreciate the opportunity to assist you in your quest to improve your life and that of your family. Please fill out the application completely and accurately. You are welcome to call our office during working hours for more information. MWF 9-5. All items with a star (*) are required. Please answer "N/A" where applicable. CONTACT INFORMATIONName* First Last * *Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PATIENT INFORMATIONPatient Name* First Last Gender*MaleFemaleDate of Birth* MM DD YYYY PREVIOUS PSYCHIATRIC TREATMENTPrevious psychiatrist :PhoneDiagnosisReason for seeking a psychiatrist at this time:*Current medications (please list psychiatric medications only):*Have you previously been hospitalized for MENTAL HEALTH REASONS?*YESNODate & length of most recent hospitalization:*Date & length of most recent hospitalization:*Reason for most recent hospitalization:*Diagnosis at most recent hospitalization:*Outcome of most recent hospitalization:*Total # of hospitalizations over lifetime for mental health:*INSURANCE INFORMATIONInsurance Company*Name of primary insured:Relationship to patient:Mental Health Benefits Administrator (we do not participate with Value Options, ComPsych or LifeSynch):Phone number for Mental Health Benefits Administrator:Policy number (ID #):*Group number:*ADDITIONAL INFORMATION:Are you currently seeking disability?*YESNON/AAre you in need of psychiatric assessment for a legal case?*YESNON/AAre you in need of treatment for a substance abuse problem?*YESNON/AI wish to see (Dr. Scott Elkin, Katie Martin, PA)*Questions, comments or concerns:It is our policy that all new appointments must be guaranteed with a credit card number. At our office, we believe that we can provide optimal care only if we have enough time set aside to adequately examine your needs and discuss your condition and treatment options in detail with you. This requires that you arrive on time for your appointment. If you are late for your appointment, we may not be able to accommodate you, and we may need to reschedule your visit. If you think that you will be late for your appointment, please call us as soon as possible so that we may advise you if your late arrival can be accommodated, or if we will need to reschedule you. All appointment changes or cancellations must be made at least 48 hours in advance to allow us to accommodate other clients. Regretfully, failure to do so, or appear for an appointment, will result in a charge to you for the booked appointment. Missed appointment fees are $125 for Dr. Elkin. By providing us with your valid credit card number, you are authorizing our office to charge your credit for missed appointment fees as stated above. Fees only apply if you miss your appointment or cancel your appointment with less than 48 business hours notice. This fee is non-refundable. Please complete the accompanying authorization form. All information is confidential. Thank you for your cooperation and understanding in this matter. We look forward to and appreciate the opportunity to assist you in your quest to improve your life and that of your family.CREDIT CARD AUTHORIZATIONPatient Name* First Last Cardholder Name* First Last Billing* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Note: We will NOT be charging your card until your appointment has been approved.*I understand by initialing this box, I understand the office policy is to provide 48-business hours to cancel or change an appointment. If I fail to provide proper notice, I understand the credit card I provide to the office to secure my appointment will be charged.