Treatment Consent
I, ___________________, consent to psychiatric evaluation and treatment by Michael B. Jackson, M. D. I
understand that he does not, and cannot, guarantee any specific results. I understand that his ability to help me/patient depends on the completeness and accuracy of the information provided to him. 2.
I consent to the exchange of information, such as diagnoses, medications prescribed, medical records, and
diagnostic test results, between Dr. Jackson, hospitals, and other treating professionals when necessary to facilitate treatment. Otherwise, I understand that psychiatric records are confidential and privileged and will not be released to anyone without proper written authorization, unless legally required. 3.
I consent specifically to the exchange of information, both for Michael B. Jackson, MD to provide and to
receive information including diagnoses, medications prescribed, medical records, and diagnostic test results from the following individuals and providers: Y
Spouse/Partner/Significant Other: ________________________________Phone:__________
Therapist: ___________________________________________________Phone:__________
School counselor: _____________________________________________Phone:__________
Primary Care Physician: ________________________________________Phone:__________
Other Medical Specialists: ______________________________________Phone:__________
Other Medical Specialists: ______________________________________Phone:__________
Other (please specify):_________________________________________Phone:___________
Other (please specify):_________________________________________Phone:___________
I consent to the release to any third party payer or its agents any information necessary for the processing
of a claim for services rendered. Should hospitalization be required, I consent to the release of any information needed for utilization review. Should prior authorization of outpatient treatment or prescription drugs be required, I consent to the release of any information needed. 5.
The undersigned agrees, whether he or she signs as guardian, agent or as patient, that in consideration of
the services to be rendered to the patient, he or she hereby individually obligates himself or herself to pay the account of the physician. Should the account be referred to an attorney or outside agency for collection, the undersigned shall pay reasonable attorney’s fees and collection expense. 6.
I agree to the terms of Dr. Jackson’s Office and Payment Policies. I understand that I am financially
responsible for all charges, and that payments are due at the end of each session. In particular, I understand that I personally must pay the full fee for the time reserved for any appointment which I miss without 24 hours notice. 7.
This consent is subject to revocation at any time, by written request, except to the extent that action has
Patient Name: _______________________________ Signature: ________________________________________
Office and Payment Policies Medications:
• To ensure quality of care, regular follow up with routine office visits is necessary for prescriptions to be
• If two or more scheduled office visits have been missed, or the time since last visit exceeds 90 days, the
patient must be seen in the office before any further prescriptions are written.
Insurance:
• Dr. Jackson's Office does not participate in any insurance plan other than Consolidated Health Plans.
• Dr. Jackson will provide a comprehensive receipt that can be submitted to an insurance company to
facilitate out-of network re-imbursement upon request.
Payment:
• All patients are financially responsible for all charges, and payments/co-pay's are due at the end of each
• Dr. Jackson's Office accepts Cash, personal checks, Visa/MasterCard.
• Requests for written reports may incur an additional charge
• There is a $25 charge for returned checks.
Cancellations:
• Because your appointment time has been reserved for you alone, you will be charged for cancellations/no
shows with less than 24 hours notice. Charges for missed appointments must be paid prior to any further appointments can be scheduled.
• Charges for missed appointments are not covered by insurance and are automatically charged to the credit
card on file unless prior arrangements are made.
• For patients with Consolidated Health Plans insurance, please note that missed visit charges include the
amount normally covered by the insurance company in addition to the copay amount.
I have read and agree to the policies listed above: _______________________________ Date: ______________
E-mail/Text Message Policies
Dr. Jackson utilizes e-mail for scheduling/rescheduling appointments and non-patient care related communications. Please be aware that the transfer of information via email is not a secure and confidential form of communication.
Dr. Jackson does not communicate via encrypted email and thus strict confidentiality cannot be guaranteed. Dr. Jackson cannot account for what the various e-mail hosting entities may do with the information contained in an email, and strongly discourages all prospective and current patients from including any health or treatment related information in an email communications with Dr. Jackson. Dr. Jackson's office does not send or receive Text Messages of any kind. Signature of acknowledgement of above: _______________________________ Date: ____________________ Due to the increased incidents of non-payments, all patients must have a credit card on file.
Please provide Visa or MasterCard (credit or debit) information below. This will only be used in the event of returned checks or other forms of non-payment, unless otherwise requested by the patient. Thank you. Credit Card # _________________________________________ Exp. Date ______________Three Digit Security Code_________ Print Name ____________________________________________ Signature _____________________________________________
M I C H A E L B . J A C K S O N , M . D . , L L C General and Forensic Psychiatrist and Diplomate of the American Board of Psychiatry & Neurology New Patient Information Form
Name:__________________________________________________________________ Today’s date:____________________
Date of birth:______/______/______ Birthplace:______________________ Social security #_________-______-___________
Home address:______________________________________________________________Phone: _______________________
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Email address:___________________________________________________________________________________________
Primary care physician:______________________________________________________ Phone:________________________
Therapist:_________________________________________________________________Phone:________________________
Pharmacy:_________________________________________________________________Phone:________________________
Emergency Contact:___________________________________________________________________Phone:________________________
Spouse/Partner Name:________________________________________________________Phone:________________________
Children (names and ages if any): ___________________________________________________________________________
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Home address:___________________________________________________________________________________________
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Educational Level Obtained:________________________________________________________________________________
Occupation:_____________________________________________________________________________________________
Employer name:___________________________________ Job title:_______________________________________________
Employment address:_____________________________________ Phone: __________________________________________
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Who referred you to this office? _____________________________________________________________________________
For what problem(s) do you seek help?
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Medication History Please list any medications/doses you are now taking. Take care to include all prescribed medication and any over-the counter medication/supplement (this includes vitamins, diet pills/drinks and herbal preparations).
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Please list all psychiatric medications that you have taken in the past. Please include the dosage, length of medication trial, and effects (both positive and negative).
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Please circle each of the following that you have taken, (even once):
CRIMINOLOGÍA DEL DESARROLLO: EL ESTUDIO DE LA PERSONALIDAD ANTISOCIAL DESDE LA PERSPECTIVA PSICOANALÍTICA Y CONDUCTUAL (SISTEMATIZANDO EL CONOCIMIENTO CRIMINOLÓGICO Y PSICOLÓGICO) SUMMARY. The next article is the compilation and study of many theories and cases related to the criminal personality, many authors have written about it, but in the study of crimin
Das Repvet Handbuch über die Regeln der Technik als Anleitung für alle Organisationen im Bereich künstliche Besamung sowiefür die zuständigen Behörden, darüber wie die Anforderungen der Richtlinie 88/407 eingehalten werden können REPVET Die REPVET Gruppe wurde bei Einführung der EU-Richtlinien zur Regelung des innergemeinschaftlichen Handelsverkehrs mit Samen gegründet. Um die