Patient Name:__________________, ________________ Last, First

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA

6351 Preston Road, Suite 205,

Frisco, TX 75034

Website : http://www.psychassociatesofnorthtx.com/

Phone: (214) 618-2225 Fax: (214) 618-8045

WELCOME

We realize that you have a choice when it comes to psychiatric care providers. Thank you for choosing Psychiatric Associates of North Texas. We welcome you as a new patient and hope that you are satisfied with the services we provide you. We look forward to seeing you as a returning patient and continuing our partnership with you thereafter.

Please complete the attached forms. These completed forms are necessary for us to meet your needs and provide you the best of care. When you have completed the forms, please return them to the receptionist’s counter and have your ID, insurance card, and payment ready. Thank you.

Welcome!

From Dr. Shakil and Staff

PleaseprintandcompleteinBLACKINKandbringintotheoffice30minutespriortoyourappointment

time.Ifyouarenotabletocompletethepaperworkpriortocomingintotheoffice,weaskthatyou

arrive45-60minutespriortoyourappointmenttocompletethenewpatientprocess.Pleaseremember

tobringinyourdriver'slicenseandinsurancecards.Shouldyouneedtochangeorcancelyour

appointment,pleasegiveourofficea72hoursnoticeasthisisascheduled45minutes

appointment.This Intake Form can also be filled online before printing. Please do not print double-sided

pages.

Pleasebeadvised,ourofficemakesconfirmationcallstonewpatients48hrsand24hrspriortotheir

appointment.Shouldweneedtoleaveamessage,itisimperativethatyoureturnthecallstoconfirmyour

appointment.Ifnoreturncalls,weassumeyouarenotcomingintotheofficeandtherefore,your

appointmentwillbecanceled.

Online Fillable Form

Basic Information 1

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA

Phone: (214) 618-2225

BASIC INFORMATION Please Print and Fill Out Completely

Patient Name:_________________________________________________________________ Last

Gender: ______

First

Date of Birth: _________________

MI

Age: _______

Address: ____________________________________________________________________ Street City State Zip Code

Home #: ___________________ Cell #:___________________Work #:__________________

Email: __________________________________ Social Security #: _____________________

Primary Care Doctor’s Name: ________________________ Office #:_____________________

Employed: Yes No (If No, check the box and skip to the next section)

Name of Employer: ____________________________ Occupation: ______________________

Address: ____________________________________________________________________ Street City State Zip Code

Highest Level of Education:_________________

Marital Status: (Please select one)

Single (Never Married) Married x ___yr Separated Divorced Widowed

Children : No Yes If yes, how many : _______

Currently live with:_____________________________________________________________

How did you hear about us? (Please select one)

Friend Relative Health Care Professional Internet Phone Book

Name of the person who referred you (if applicable): __________________________________

Referring Doctor/Hospital Name: _______________________ Office #:________________ (Required if you are being referred by another provider)

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA

Phone: (214) 618-2225

Basic Information 2

WHO SHOULD WE CONTACT IN CASE OF EMERGENCY?

Name: _______________________________________ Phone #: _______________________

Address: ____________________________________________________________________

Relationship to Patient: _________________________________________________________

Insurance: _________________________ Policy Holder Name: ________________________

Group #: _________________________________ Member ID: ________________________

RESPONSIBLE PARTY

Who is the guarantor? (Who will be responsible for paying?) For example, if the patient is a minor, this might be a parent/guardian. If the claim to be filed on an insurance policy your spouse has through their employer, this would be your spouse’s information.

Same as Patient (If you are the patient and will be responsible for the finances, check the box and skip to the next section)

Name:_______________________________________________________________________ Last First MI

Social Security # ________________________________ Date of Birth ___________________

Address: ____________________________________________________________________ Street City State Zip Code

Home #: ___________________ Cell #:___________________Work #:__________________

Occupation: ___________________________Employer:_______________________________

Employer Address: ____________________________________________________________ Street City State Zip Code

Patient/Guardian Signature :_____________________________ Date: __________________

Name of legal guardian/caretaker (if applicable): __________________________________

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA

Phone: (214) 618-2225

CONTACT AND DISCLOSURE AUTHORIZATION

Print Patient Name: ___________________________________ Date: _____________

Please contact me in the following ways: (check all that apply)

By my home phone, my number is: _______________________________

It is ok to leave me a message with detailed information.

It is NOT ok to leave me a message with detailed information.

By my cell phone, my number is: _________________________________

It is ok to leave me a message with detailed information.

It is NOT ok to leave me a message with detailed information.

By my work phone, my number is: ________________________________

It is ok to leave me a message at work with detailed information.

It is NOT ok to leave me a message at work with detailed information.

It is ok to only leave a call back number at my work number.

I authorize you to discuss my medical history and release any and all medical information to the following people: (complete all that apply)

My spouse, whose name is: ____________________________ Phone ________________

My parent, whose name is: ____________________________ Phone ________________

No one other than myself

Another person I choose: ______________________________ Phone ________________ Last First

Patient/Guardian Signature: ________________________________________________

Name of legal guardian/caretaker (if applicable): __________________________________

Contact and Disclosure Authorization 3

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA

Phone: (214) 618-2225

PATIENT HISTORY

Print Patient Name: _____________________________________________ Date: _______________

Drug Allergies: ___________________________________________________________________________

Medical History: HIV Asthma Bronchitis Emphysema COPD Hard of Hearing Sleep Apnea ENT Problems Seizures Sinus Problems Ulcers Congestive Heart Failure Hepatitis Type ______________ Liver Disease High Blood Pressure Heart Attack Heart Disease Pacemaker Stroke Chest Pain Chronic Pain Palpitations Heart Murmur High Cholesterol Diabetes Thyroid Problems Anemia Bleeding Disorder GI Problems Gyn Problems Prostate Problems Kidney/Bladder Issues Back/Neck Problems Glaucoma Arthritis Cancer ___________________ Head Injury Chronic Lung Disorder

Other Significant Illness __________________________________________________________________

Check all symptoms that apply: Sad/Depressed Mood Feeling Hopeless Severe Anxiety Panic Attack Mood Swings Paranoia Poor Sleeping Sleeping too much Social Fears or Withdrawal Anger Outbursts Hearing Voices Trouble Remembering Loss of Energy Poor Attention Poor Memory Easily Distracted Confusion Seizures Sexual Problems Hallucinations Suspicious Feelings Racing Thoughts Trouble Concentrating Thoughts about Suicide Dizziness/Fainting Tightness/Chest Pain Ringing in Ears Marital or Family Problems GI Problems Anemia Prostate Problems Blurred Vision Nausea/Vomiting Trouble Eating/Appetite Problems Constipation Diarrhea Menstrual Problems Frequent Urge to Urinate Frequent Headaches/Migraines

Other Significant Symptoms : ______________________________________________________________

On average how many hours per night have you been sleeping over the past 2 weeks ? __________________

Have you ever been physically and/or sexually abused ? No Yes

Do you smoke cigarettes? No Yes How long? __________________ Packs per day? ___________

If No, previous cigarettes smoker? No Yes How long? ____________ Packs per day? ___________

Do you drink alcohol ? No Yes Drinks per week? _________________

Patient History 4

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA

Phone: (214) 618-2225

Patient History 5

Women :

Is there a possibility that you are pregnant ? No Yes

Are you considering pregnancy ? No Yes Date of Last Menstrual Period ________________

Are you taking birth control pills? No Yes Are you Nursing? No Yes

Have you ever experimented with and/or abused any of the following?

Marijuana Cocaine LSD PCP Methamphetamines (Ice, Crank, Speed, Crystal Meth, Speed) Opiates (Heroin, Oxycontin, Oxycodone, Percodan, Percocet, Hydrocodone, Lortab, Norco, Vicodin, Morphine) Benzodiazepines (Xanax, Ativan, Valium, Klonopin) Other: ______________________________________

Are you currently using any of the following? Marijuana Cocaine LSD PCP Methamphetamines (Ice, Crank, Speed, Crystal Meth, Speed)

Opiates (Heroin, Oxycontin, Oxycodone, Percodan, Percocet, Hydrocodone, Lortab, Norco, Vicodin, Morphine) Benzodiazepines not prescribed for you (Xanax, Ativan, Valium, Klonopin) Other: _____________________

Have any of your relatives been treated for Psychiatric Disorders? No Yes

If Yes then,

Depression Schizophrenia Bipolar Anxiety Disorder

ADHD Substance Abuse

Suicide Attempts OR Suicide Completed

Mother Father Sibling Children Grand Parents Uncle/ Aunts Cousins

Current Medications Name(including non-prescription) Dosage Times per day

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Patient History 6

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA

Phone: (214) 618-2225

Past Psychiatric Medications:

Name How long taken When stopped

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Past Hospitalizations for Psychiatric Illness:

Where Date Reason

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Past Hospitalizations for Other Medical Illness or Surgery:

Where Date Reason and Procedure (if applicable)

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Presenting Problems 7

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA

Phone: (214) 618-2225

PRESENTING PROBLEMS

Print Patient Name: ____________________________________ Date: ____________

Please tell us what problem(s) brought you to our office today?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

When did the problem(s) first begin?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

What symptoms are you currently experiencing?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Is there anything else you would like us to know?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA

Phone: (214) 618-2225

Office Policies 8

OFFICE POLICIES

• Professionalism and Service. Our office strives to meet the highest standards of quality andprofessionalism. We seek to provide excellent patient care in a respectful and cooperativeenvironment.

• Feedback. Patients are our first priority. We welcome your feedback about your experience here andthe service we provide you. Please let us know how we are doing.

• Confidentiality. Doctor - Patient confidentiality is the cornerstone of psychiatric treatment. A copy ofthe full HIPAA NOTICE OF PRIVACY PRACTICES is included with the new patient forms and shouldbe reviewed and signed. It is often helpful for Dr. Shakil to communicate with other physicians ortherapists. She may ask for your permission to communicate with your other physicians or therapists inorder to enhance your continuity of care.

• Client Communications. For routine matters, please leave a message on the office phone numberand Dr. Shakil will return your call as soon as possible, generally within 1 business day.

• Psychiatric Emergencies. For emergencies, please call 911 or go to the nearest emergency room.

• Prescription Refills. New prescriptions will not be issued without first seeing Dr. Shakil. Allprescription refill requests require 2 business days notice. It is the patient's responsibility to monitor theprescription prior to depletion and call the clinic to request a prescription. Prescriptions for a stimulantmedication (Schedule II controlled substance) CANNOT be called or faxed into the pharmacy andMUST be filled within 21 days.

• Form Completion. All forms requiring medical review and physician signature – including FMLA,disability or other paperwork is subject to an administrative fee. Filling in such forms requires monitoringof psychiatric condition. There are a minimum of 5 office visits required to properly monitor thepsychiatric condition before such forms can be filled in by the clinic. Final determination of disability issolely upon the physician.

• Appointments. Office visits are by appointment only. Please arrive at least 15 minutes before yourscheduled appointment.

• Courtesy. Please turn off the ringer volume on your cell phone and refrain from leaving childrenunattended.

• Termination. We reserve the right to stop providing services to patients who are non-compliant withtreatment, do not pay for services, miss more than three scheduled appointments, or for other reasonswe deem reasonable.

I have read, have understood, and do accept and agree to comply with all of the above office policies.

Patient/Guardian Signature: ____________________________________________ Date: ________________

Patient Name: ____________________________________________________________________________

Name of legal guardian/caretaker (if applicable): ___________________________________________

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA

Phone: (214) 618-2225

Financial Policies

FINANCIAL POLICIES

Thank you for choosing the Psychiatric Associates of North Texas for your medical care. We are committed to providing you with quality personal health care. To reduce confusion or misunderstanding, we ask that you read this policy, ask any questions that you may have, and sign the Authorization and Acknowledgment section of this form. Other than for true medical emergencies, agreement with this policy is required for all medical care.

• Payment. Payment must be made at the time we provide services to you. There are no exceptions.We accept the following forms of payment: Cash, Debit Card, Personal Check, American Express,Discover, Master Card and Visa. In case of Insurance, Copay/Deductibles must be made at the time ofservice. Overdue balance would be calculated after the insurance payment. Payment would becomedue then.

• Insurance: We participate in most of the major healthcare insurance plans and will bill your insuranceplan as may be necessary. If we do not participate with your healthcare insurance plan, payment in fullis required at the time of service. Knowing your insurance benefits – including eligibility, coveredbenefits, and medically necessary procedures is your responsibility; please contact customer servicesat your insurance company for questions you may have regarding your coverage. You are responsiblefor any services not covered by your plan.

• Proof of Insurance. All patients must complete and/or update our Patient Information Form at eachoffice visit. You must furnish valid and up-to-date proof of insurance coverage and a copy of yourdriver’s license. If you provide false or expired insurance information you will be responsible for thebalance of the claim. Please notify us of any changes in insurance coverage prior to the time ofservice. Insurance denials for termination of coverage will be automatically billed to you.

• Co-payments and deductibles. All co-payments, deductibles and co-insurance must be paid atthe time of service. Protection of your insurance benefits requires us to charge for, and you to payfor, all required co-payments, co-insurances, deductible and non-covered services.

• Claim submission. We will submit your insurance claims and assist you in any way reasonable tohelp get your claim paid. Your insurance company may need you to supply information directly tothem. It is your responsibility to comply with their request in a timely manner. Texas insurance lawrequires your insurance company to provide timely payment. Please be aware that the balance ofyour claim is your responsibility to pay whether or not your insurance company has paid. We arenot a party to your insurance contract.

• Referrals. If your managed care plan requires prior approval or authorization for referrals to aspecialist it is your responsibility to arrange for the referral prior to your appointment with Dr Shakil.Retroactive referrals cannot be accepted.

• OTHER SERVICES, CHARGES AND PATIENT RESPONSIBILITIES: Insurance coverage generallydoes not include coverage for many administrative services, such as requests for information and formcompletion. The following services may have an administrative service charge that will be billeddirectly to you and are your responsibility for payment. Our practice is committed to providing thehighest quality of service to our patients while keeping our charges for administrative services at orbelow the usual and customary charges of other medical practices in our area. All such administrativefees must be paid prior to scheduling future appointments.

9

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA

Phone: (214) 618-2225

Financial Policies 10

• Missed appointments. Broken appointments represent not only a cost to us, but also an inability toprovide services to others who could have been seen in the time set aside for you. If you are latefor your appointment, we may cancel it to facilitate our clinic operations. If you cannot be at yourscheduled appointment, you must contact the office as soon as possible. If you cancel yourappointment less than 24 hours in advance, you will be charged $50 which must be paid beforeyour next scheduled appointment.

• Form completion. All forms requiring medical review and physician signature – including FMLA,disability or other paperwork is subject to an administrative fee of $35.00. Filling in such formsrequires monitoring of psychiatric condition. There are a minimum of 5 office visits required toproperly monitor the psychiatric condition before such forms can be filled in by the clinic. Finaldetermination of disability is solely upon the physician.

• Requests for Medical Records. Psychiatric Associates of North Texas requires written requestsfor the release of medical records in accordance with Texas law. The administrative fee associatedwith copying medical records is based on current Texas law, which allows up to 15 business daysto release the requested copies to you. Please take this into consideration when requesting copiesof your medical records. There will be a fee for expedited copies of medical records. There is a$25.00 fee for written correspondence to an employer or school (excluding excuses from work orschool due to illness or clinic visits).

• Care for minors. A parent or legal guardian must accompany minor patients on their visits. Theaccompanying adult is responsible for payment of the account, according to the policy outlinedabove.

• Delinquent accounts. Statements will be mailed for outstanding balances. If more than onestatement is mailed in an attempt to collect an outstanding debt an administrative fee may beassessed. Delinquent accounts will be submitted to an outside collection agency once the paymentdue is past 60 days. If your account is transferred out of our office for collection, you will beresponsible for all fees incurred by Psychiatric Associates of North Texas to collect youroutstanding debt.

• Returned checks: Returned checks will incur a fee of $35.00. If more than one returned check isreceived on your account, we will require all future payments be made by cash, cashier’s check orcredit card. Any checks that are not paid will be filed with the District Attorney’s office for collection.All fees incurred in the filing will be your responsibility.

I have read, have understood, and do accept and agree to comply with all of the above financial policies.

Patient/Guardian Signature: ____________________________________________ Date: ________________

Patient Name: _______________________________________________________________________

Name of legal guardian/caretaker (if applicable): _____________________________________________

Psychiatric Associates of North Texas, PA Phone: (214) 618-2225

Privacy Officer: Rubina Shakil, M.D.

HIPAA NOTICE OF PRIVACY PRACTICES

Effective Date : September 23rd, 2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GETA CCESS TOT HIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. This notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our Privacy Officer listed above.

TABLE OF CONTENTS A. How This Medical Practice May Use or Disclose Your Health Information ........................... 11B. When This Medical Practice May Not Use or Disclose Your Health Information .................. 14C. Your Health Information Rights.............................................................................................. 14

1. Right to Request Special Privacy Protections2. Right to Request Confidential Communications3. Right to Inspect and Copy4. Right to Amend or Supplement5. Right to an Accounting of Disclosures6. Right to a Paper or Electronic Copy of this Notice

D. Changes to this Notice of Privacy Practices ......................................................................... 15E. Complaints ............................................................................................................................ 15

A. How This Medical Practice May Use or Disclose Your Health InformationThis medical practice collects health information about you and stores it in a chart [and on a computerand in an electronic health record/personal health record]. This is your medical record. The medicalrecord is the property of this medical practice, but the information in the medical record belongs to you.The law permits us to use or disclose your health information for the following purposes:1. Treatment. We use medical information about you to provide your medical care. We disclose

medical information to our employees and others who are involved in providing the care you need.For example, we may share your medical information with other physicians or other health careproviders who will provide services that we do not provide. Or we may share this information witha pharmacist who needs it to dispense a prescription to you, or laboratory that performs a test. Wemay also disclose medical information to members of your family or others who can help you whenyou are sick or injured, or after you die.

2. Payment. We use and disclose medical information about you to obtain payment for the serviceswe provide. For example, we give your health plan the information it requires before it will pay us.We may also disclose information to other health care providers to assist them in obtainingpayment for services they have provided to you.

Copyright 2013 American Medical Association. All rights reserved 11

3. Health Care Operations. We may use and disclose medical information about you to operate this medical practice. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff. Or we may use and disclose this information to get your health plan to authorize services or referrals. We may also use and disclose this information as necessary for medical reviews, legal services and audits, including fraud and abuse detection and compliance programs and business planning and management. We may also share your medical information with our "business associates," such as our billing service, that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your protected health information. We may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help them with their quality assessment and improvement activities, their patient-safety activities, their population-based efforts to improve health or reduce health care costs, their protocol development, case management or care-coordination activities, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, or their health care fraud and abuse detection and compliance efforts. [Participants in organized health care arrangements only should add: We may also share medical information about you with the other health care providers, health care clearinghouses and health plans that participate with us in "organized health care arrangements" (OHCAs) for any of the OHCAs' health care operations. OHCAs include hospitals, physician organizations, health plans, and other entities which collectively provide health care services. A listing of the OHCAs we participate in is available from us

4. Appointment Reminders. We may use and disclose medical information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.]

5. Sign In Sheet. We may use and disclose medical information about you by having you sign in when you arrive at our office. We may also call out your name when we are ready to see you.

6. Notification and Communication With Family. We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or, unless you had instructed us otherwise, in the event of your death. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others.

7. Marketing. Provided we do not receive any payment for making these communications, we may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments, therapies, health care providers or settings of care that may be of interest to you. We may similarly describe products or services provided by this practice and tell you which health plans this practice participates in. We may also encourage you to maintain a healthy lifestyle and get recommended tests, participate in a disease management program, provide you with small gifts, tell you about government sponsored health programs or encourage you to purchase a product or service when we see you, for which we may be paid. Finally, we may receive compensation which covers our cost of reminding you to take and refill your medication, or otherwise communicate about a drug or biologic that is currently prescribed for you. We will not otherwise use or disclose your medical information for marketing purposes or accept any payment for other marketing communications without your prior written authorization. The authorization will disclose whether we receive any compensation for any marketing activity you authorize, and we will stop any future marketing activity to the extent you revoke that authorization.

Copyright 2013 American Medical Association. All rights reserved 12

8. Sale of Health Information. We will not sell your health information without your prior written authorization. The authorization will disclose that we will receive compensation for your health information if you authorize us to sell it, and we will stop any future sales of your information to the extent that you revoke that authorization.

9. Required by Law. As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities.

10. Public Health. We may, and are sometimes required by law, to disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.

11. Health Oversight Activities. We may, and are sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by law.

12. Judicial and Administrative Proceedings. We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.

13. Law Enforcement. We may, and are sometimes required by law, to disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.

14. Coroners. We may, and are often required by law, to disclose your health information to coroners in connection with their investigations of deaths.

15. Organ or Tissue Donation. We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.

16. Public Safety. We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

17. Proof of Immunization. We will disclose proof of immunization to a school that is required to have it before admitting a student where you have agreed to the disclosure on behalf of yourself or your dependent.

18. Specialized Government Functions. We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.

19. Workers’ Compensation. We may disclose your health information as necessary to comply with workers’ compensation laws. For example, to the extent your care is covered by workers' compensation, we will make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or workers' compensation insurer.

20. Change of Ownership. In the event that this medical practice is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another physician or medical group.

21. Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law. If you have provided us with a current e-mail address, we may use e-mail to communicate information related to the breach. In some circumstances our business associate may provide the notification. We may also provide notification by other methods as appropriate intercepted

Copyright 2013 American Medical Association. All rights reserved 13

20. Research. We may disclose your health information to researchers conducting research with respect towhich your written authorization is not required as approved by an Institutional Review Board or privacy board, in compliance with governing law.

B. When This Medical Practice May Not Use or Disclose Your Health InformationExcept as described in this Notice of Privacy Practices, this medical practice will, consistent with its legal obligations, not use or disclose health information which identifies you without your written authorization. If you do authorize this medical practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.

C. Your Health Information Rights1. Right to Request Special Privacy Protections. You have the right to request restrictions on

certain uses and disclosures of your health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. If you tell us not to disclose information to your commercial health plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and will notify you of our decision.

2. Right to Request Confidential Communications. You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.

3. Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can’t agree and we maintain the record in an electronic format, your choice of a readable electronic or hardcopy format. We will also send a copy to any other person you designate in writing. We will charge a reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary. We may deny your request under limited circumstances. If we deny your request to access your child's records or the records of an incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial harm to the patient, you will have a right to appeal our decision. If we deny your request to access your psychotherapy notes, you will have the right to have them transferred to another mental health professional.

4. Right to Amend or Supplement. You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about this medical practice's denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information.

Copyright 2013 American Medical Association. All rights reserved 14

5. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6 (notification and communication with family) and 18 (specialized government functions) of Section A of this Notice of Privacy Practices or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent this medical practice has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities.

6. Right to a Paper or Electronic Copy of this Notice. You have a right to notice of our legal duties and privacy practices with respect to your health information, including a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by e-mail.

If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices.

Copyright 2013 American Medical Association. All rights reserved 15

D. Changes to this Notice of Privacy PracticesWe reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted in our reception area, and a copy will be available at each appointment.

E. ComplaintsComplaints about this Notice of Privacy Practices or how this medical practice handles your health information should be directed to our Privacy Officer listed at the top of this Notice of Privacy Practices.

If you are not satisfied with the manner in which this office handles a complaint, you may submi a formal complaint to:

www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf OCRMail@hhs.govYou will not be penalized in any way for filing a complaint.

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA Phone:

(214) 618-2225

HIPAA NOTICE OF PRIVACY PRACTICES

PATIENT/GUARDIAN ACKNOWLEDGMENT/CONSENT

By my signature below, I acknowledge receipt of "HIPAA NOTICE OF PRIVACY PRACTICES". I have read this Notice and I understand it. I have been given the opportunity to ask questions about this Notice and my privacy rights.

By my signature below, I also consent to the use or disclosure of my Protected Health Information as

described above.

I understand that I may revoke my consent at any time by giving written notice.

I understand that this consent is voluntary and that I may refuse to sign it. I understand that if I do not

grant my consent, however, you are legally permitted to refuse to provide health care services to me.

Patient/Guardian Signature: _______________________________ Date: ________________

Patient Name: _______________________________________________________________

Name of legal guardian/caretaker (if applicable): ____________________________________

HIPAA Notice of Privacy Practices 16

I understand that all information shared with the mental health providers at Psychiatric Associates of North Texas, P.A. is confidential and no information will be released to anyone outside of the practice without my consent. I further understand that there are specific and limited exceptions to this confidentiality which include the following:

A. When there is risk of imminent danger to myself or to another person, the staff at PsychiatricAssociates of North Texas, P.A. is ethically bound to take necessary steps to prevent such danger.

B. When there is suspicion that a child or elder is being abused or is at risk of being abused, the staffat Psychiatric Associates of North Texas, P.A. is legally required to take steps to protect the childor elderly, and to inform the proper authorities.

C. When a valid court order is issued for medical records, the staff at Psychiatric Associates of NorthTexas, P.A. is bound by law to comply with such requests.

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA

Phone: (214) 618-2225

CONTROLLED SUBSTANCE POLICIES

Please be advised that it is extremely hazardous to obtain prescription medications for controlled substances from numerous providers. Patients who receive prescription drugs such as controlled substances from pharmacies shall provide our office with prior written authorization to communicate with pharmacies as well as other providers for the purpose of compliance with this various regulations and policies. As a result of affixing your signature to this policy, you moreover concur with the pursuing regulations in an effort to safeguard you in addition to prescribing providers.

• You acknowledge and agree to notify our clinic of any new medications as well as any all medical conditions and/or adverse affects you experience from any of the medications that you consume. You shall utilize the prescribed dosage for the prescribed controlled substance. You will not share, sell, trade, exchange your prescription(s) for revenue, products, services or in any other manner enable other individuals to possess use of this (these) prescription(s). You consent to keep and/or maintain this (these) prescription(s) in a secure and safe location.

• Determination of medication and dosage is solely Dr. Shakil’s decision based on her evaluation of your medical condition and determination of medical necessity.

• Refills are exclusively provided as determined by Dr. Shakil; absolutely no premature refills will be provided regardless of the circumstances (i.e., stolen, misplaced, mislaid, exceeding prescribed dosage etcetera).

• Schedule II Controlled Substance prescriptions pertaining to stimulant drugs (Adderall, Ritalin, Concerta, Dexedrine, Dextrostat, Daytrana, etcetera.) cannot be telephoned or faxed to the pharmacies and MUST be filled within 21 days (twenty-one days.) In circumstance where a prescription for any stimulant medication is not filled within 21 days (twenty-one days,) the expired prescription must be returned before a new prescription can be reissued. Please note there shall be a $20.00 (twenty-dollar) charge to rewrite expired prescriptions.

• Changes and/or alterations in prescriptions shall only be made in the course of clinic visits and never via telephone and / or during non-clinic hours.

• Urine drug screenings may be requested to track your consumption of prescribed controlled substances and to screen for the use of illegal substances. Refusal to consent to such testing shall subject you to a medication taper schedule and may result in the discontinuance of your prescription.

• Altering the date, quantity, and / or strength of medications or altering a prescription by any means, shape, or form is prohibited.

Forging prescriptions and / or Dr. Shakil’s physician's signature is prohibited and violates state and federal law. Our clinic fully cooperates with local, state and federal law enforcement agencies as well as the Drug Enforcement Agency (DEA) in regard to infractions involving prescription medications. The patient’s pharmacy, local authorities, and DEA will be notified if the treating physician believes the law has been violated in any manner by the patient.

If it is determined that any of the above policies have been violated, all orders for these prescriptions will cease and the patient may be dismissed from the care of this office.

Controlled Substance Policies 17

Rubina Shakil, M.D. Psychiatric Associates of North Texas, PA

Phone: (214) 618-2225

Print Patient Name: ____________________________________ Date: ____________

ACKNOWLEDGEMENT OF CONTROLLED SUBSTANCE POLICY:

I have read and understand the policies regarding controlled substance prescriptions. I agree to the terms involved in the Controlled Substance Policy and have received a copy of this policy. I understand that if any of the above policies are violated or I choose not to adhere to these policies, I will be dismissed from this clinic and will not receive any refills from the treating physician.

Patient/Guardian Signature: _______________________________

Name of legal guardian/caretaker (if applicable): ____________________________________

COUNSELING SERVICES AGREEMENT

I understand that while counseling may provide significant benefits, it may also pose risks. Counseling may cause me to experience uncomfortable thoughts and feelings, or may lead me to recollect distressing memories.

I hereby consent to participate in counseling services offered to me by Psychiatric Associates of North Texas, P.A. I understand that I have the right to stop treatment at any time.

Patient/Guardian Signature: ________________________________

Name of legal guardian/caretaker (if applicable): ______________________________________

Controlled Substance Policies Counseling Services Agreement 18