New Patient Intake Form
Consent to Treatment - I authorize and consent to medical care and treatment by Thomas Cook, MD (“Dr. Cook”) and Happy Happy Happy, LLC and Beyond Mental Health, (collectively, “Dr. Cook’s Office”) including diagnostic tests and procedures, which
Dr. Cook finds necessary according to his professional judgment and which Dr. Cook’s office gives and/or performs. Ongoing consent for any particular treatment or test, including pharmaceuticals, genomic testing, urine drug screens, will be obtained verbally,
and documented with signatures when appropriate. Regarding treatment locations, I understand that Dr. Cook may practice from
more than one location, and that Dr. Cook’s Office may be working out of any one of several locations. I understand that each of
these clinics are scheduled independently, and I agree that all follow-up appointments will occur at the same location as the one in
which I was originally seen. I understand that that there are several collaborative providers at Dr. Cook’s Office, that Dr. Cook will
assign me to the best provider for my case, that this determination is his prerogative alone, and finally, that I may be obliged to
switch providers at any time due to scheduling availability. I understand that the length of each E/M appointment is the prerogative
of the providers in Dr. Cook’s Office, based on their clinical judgment. I understand that in some rare instances, (e.g., TMS/keta- mine) Dr. Cook’s Office serves as a consulting and procedural clinic only, and that the primary responsible psychiatrist may be outside Dr. Cook’s Office.
Record-keeping - Dr. Cook keeps records of each session noting the dates we meet, the topics we cover, progress reports from the
client’s perspective, interventions, Dr. Cook’s diagnostic impressions, and next steps. This form itself is also a part of my medical
record. I understand that Dr. Cook’s EMR system is not an exhaustive or complete medical record, and that my medical record may
include extra psychotherapy notes, psychometric testing, symptom scale, or other forms that are not stored electronically. It is my
understanding that the medical info I have entered above on this form is both correct and complete. I attest that the current medication list I have written down is indeed a complete list of all my current medications, that the allergy list is a complete list of allergies, and that the ‘medical conditions’ line is a complete list of all pre-existing medical or psychiatric conditions diagnosed by other
doctors. Regarding access to records, you are entitled to receive a copy of the records unless, in Dr. Cook’s medical opinion, allowing
you to see the records would be detrimental to your health, in which case Dr. Cook’s office would be happy to make them available
to an attorney authorized by you to receive the records. Because these are professional records, they can be misinterpreted and/or
upsetting to untrained readers. It is recommended that you review treatment records in Dr. Cook’s presence so that you can discuss
the contents with him.
Diagnosis - If a third party such as an insurance company is paying for part of your bill, that third party normally must be given a
diagnosis before paying the bill. Diagnoses are technical terms that describe the nature of your problems and indicate whether
they are short-term or long-term problems. If Dr. Cook makes a diagnosis, he will discuss it with you.
Waiting Room - I understand that my personal belongings may be lost or stolen while in the Varsity Building or while in the office
or on the premises of Dr. Cook’s office, and that I will not hold Dr. Cook’s Office responsible for these lost or stolen items. I also
understand that Dr. Cook’s Office will not be responsible for any injuries sustained while on the premises.
Missed Appointments - I understand that if I miss more than one scheduled appointment, I may or may not incur a $50 no-show fee. I understand that if I miss many appointments, I may be terminated from care. If I cannot keep the scheduled appointment, I
agree to inform Dr. Cook’s Office at least 48 hours prior to the appointment.
Phone Calls/Text/Emails - I am aware that Dr. Cook may or may not respond to emails I send him, that I may be charged $50 for
any electronic communication which leads to clinical decision making such as medication changes or other recommendations. I
understand that unencrypted email is not intrinsically a confidential means of communication. By using unencrypted email, and
by engaging with Dr. Cook in email communications, I consent to the remote, but real, risk of exposure of my protected health information. If I have provided a personal email on the intake form, I thereby give consent, unless I directly state otherwise, for Dr.
Cook’s Office to send my protected health information to me by that unencrypted route. I realize that Dr. Cook’s Office is not an
urgent care clinic, that physician’s exchange is an available service, and that Dr. Cook will try to return calls in a reasonable time
frame, but that if I am in grave danger of harming myself, I won’t wait for a returned call but will immediately go to an emergency
room. I realize all electronic communication is neither an efficient nor a rapid means of communication, and it is neither my understanding, nor my expectation, that electronic text/email communications with Dr. Cook’s Office will pertain to, or be intended
to address, any urgent matters whatsoever.
Confidentiality - I understand my medical information may be shared with certain insurance carriers to assess the necessity of
treatment, and that the policy of Dr. Cook’s Office is to share with them no more information than they need to know to accomplish
that task. I may consult my insurance documents to determine what level of access to my records I have authorized my insurance
carrier to receive. I understand that my medical information may be shared with pharmacists and their assistants, and I give consent for Dr. Cook’s Office to look up my Rx history with the Hawaii Prescription Drug Monitoring Program. I realize and consent to
the fact that all ancillary staff working in Dr. Cook’s Office may need to access my detailed medical records. If I request a sick leave
notification from Dr. Cook, I understand that this may entail my boss or other officials at my place of work knowing full well that I
am under the care of a psychiatrist and may have a mental health diagnosis.
Pregnancy - I understand that if I am pregnant, if I become pregnant, or if I intend to become pregnant while a patient of Dr. Cook’s Office, I must disclose this information to Dr. Cook’s Office. Failure to do so will result in a termination of this contract and
the doctor-patient relationship.
Release of Specially Protected Health Information - If my medical record contains any information related to HIV or AIDS, mental health diagnosis and treatment, or federally funded substance abuse treatment programs, I consent to release such health in- formation for the purpose of treatment for obtaining authorization or payment from my insurers and other payers and for other
specific insurer/payor requirements, within the limits of the law. I understand that I may choose to pay for treatment in which case
my health information will not be provided to my insurance company, but that I must make arrangement for payment before services are provided, or on the day services are provided, and that if I fail to make payment within 30 days (or as otherwise agreed in
writing), the health information may be disclosed to my insurance company<./p>
Eligibility - I understand that it is my responsibility to keep track of my eligibility status. If I consent to see Dr. Cook for a clinical
visit, thinking I am eligible, when I am not in fact eligible for services, I will incur the self-pay rate for the visit.
Self Pay - If I do not have active medical insurance, or if my insurance does not cover outpatient behavioral health services, I un- derstand that self-pay forms accepted may include cash, credit card, debit card, or check. I understand the charge for an evaluation
is $300, and for a follow up visit is $150. I understand co-payment may be made by the same means. I understand that if I authorize
Dr. Cook to make lengthy phone calls (e.g., longer than 10 minutes) for my care, e.g. to gather history, update other individuals
about my treatment, or for other purposes, I may incur a self-pay charge between $50 -$150.
Financial Agreement - I understand that all copays are due at time of visit, and that I am responsible for all deductibles, copays,
and non-covered benefits, and that I will pay Dr. Cook’s Office in full, within 30 days (or longer if required by law) unless I make
other arrangements with Dr. Cook’s Office. I realize if my check bounces, and the bank charges Dr. Cook’s Office a fee, I will be re- sponsible for that fee. Bill Collection: a late payment charge of 1% per month, calculated at simple interest, may be assessed on
my account if not paid in full within 30 days (or longer if required by law). If the bill is not paid in full within 30 days (or longer if
required by law) I understand that Dr. Cook’s Office may refer the matter to an attorney and/or collection agency, and that I will be
responsible for paying all legal fees and other costs incurred to collect my bill.
Medicare / Medicaid - If I have Medicare or Medicaid coverage, I certify that the information given by me in applying for payment is correct. I understand that the Social Security Administration may release information on my Medicare effective dates and
Medicare claim number to Dr. Cook’s Office. I request that payment of benefits be made to Dr. Cook’s Office on my behalf. I consent to the release of my information related to Medicare and Medicaid coverage as needed for payment of this claim and related
claims. I understand that I am responsible for paying my bill in full. If I am entitled to any insurance benefits, I assign all of these
benefits to Dr. Cook’s Office toward payment of my bill and I direct my insurance carrier to pay these benefits to Dr. Cook’s Office.
I understand that Dr. Cook’s Office will bill my insurance carrier if I provide benefits information in a timely fashion.
Termination - I understand the physician-patient relationship is a voluntary one, and that I may be terminated as a patient for any
reasonable reason, including, but not limited to, if I do not return calls or mail, if I stop medication without notifying a provider, if I
do not take medications as prescribed, if I am unruly, rude, threatening, inappropriate, or harassing to any office staff, if I am disruptive, if I exhibit poor boundaries with staff or with other patients in the waiting area, if Dr. Cook concludes that my problems
would be better addressed by another physician, or if there is any indication that I am not reliably honest in the information I give
to Dr. Cook’s Office.
By signing below, I certify that I have read the Terms and Conditions of Service above and that I understand that I am responsible
for all charges, regardless of insurance coverage. By signing below, I also certify that I consent in full to the privacy statement above,
as well as the privacy practices of Dr. Cook’s Office, and that I agree to be bound by them, and that I am the patient, or the patient’s
authorized representative. I am aware that a copy of the Privacy Notice for Dr. Cook’s Office is readily available in the office for any- one to read. I hereby acknowledge that I may obtain a copy of the Privacy Notice from the receptionist, or from Dr. Cook, if I wish.
What is a Guarantor? A guarantor is the person responsible for payment. If guarantor is NOT the patient,
then both patient AND guarantor must sign.
New Patient Intake Form - Guarantor Version
Place: 1401 S. Beretania St. Suite 450, Honolulu, HI 96814
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: New Patient Intake Form
Agree & Sign