Clinical & Forensic Psychiatry
 

Patient Form & Payment Info.

Please Print and Fill out this Form:

FAX it me at 970-987-5100. Or scan it into your computer and e-mail it to me at:
jerrysteinmd@gmail.com




Gerald S Stein MD
Multiple Board Certifications

Adult Civil and Criminal
Forensic Psychiatry and Clinical.

OFFICES: Eureka Springs
645 CR 235
Eureka Springs,Arkansas 72632

t:[479]253-2849, c:[479]244-6582 e:jerrysteinmd@gmail.com
PATIENT NAME:


DATE OF BIRTH:


MALE FEMALE


Address:


City:


State:


Zip Code:



Telephone #'s

Home:

work:

cell:


Credit card:

Expiration Date:

3 Digit Code:

e-mail:

Current Medications & Allergies: list drug allergies, drugs being used and dosage on back of page

PAYMENT MUST BE MADE AT TIME SERVICES ARE PROVIDED.

VISA and MASTER CARD CARDS ACCEPTED, but you are responsible for all charges, if your credit card company does not pay for any reason.

I will provide bills at least monthly, which will include the information needed for you to be reimbursed by your medical insurance company.


Time spent on your behalf between visits, including lengthy telephone calls and e-mails will be charged at my standard rate with charges for prescriptions needed between appointments.

Continuing to prescribe most medications will require periodic in-person visits to examine for optimal effectiveness, side- effects and newly available alternative drugs.

I schedule only one patient for each hour, so an appointment which is not kept wastes an hour that another patient might have used. The more notice I get of a cancellation, the greater the chance that I will be able to use that time for another patient. If you cancel less than a week in advance and I cannot use the time I have reserved for you, or if you just do not come in, the session charge will be charged to your credit card.

Please read information on the second page and keep a copy.

I have read, understood and accept these patient responsibilities. I agree that I will be responsible for all treatment charges, including accepting the policy on cancellations.

___________________________________
Sign: Patient
Responsible party [if applicable]

_________________________
Date




FYI: Since psychotherapists are often required to divulge their training and qualifications, let me provide my medical/psychiatric background:


I was named the national Professional of the Year 2008 in Psychiatry. I have been included in the BEST DOCTORS IN AMERICA and TOP PSYCHIATRISTS for many years. My first psychotherapy paper won the national 1984 Hoedemaker Prize given to the outstanding clinical paper of the year. My most recent work, a DVD entitled HUMAN/NATURE won the seldom given Herbert S. Gaskill Prize for outstanding achievement in 2008 and was shown at the Independent Film Festival. Fifteen other papers and a book have been published.


I’ve had the good fortune to have unusually extensive training at several top medical centers: undergraduate and medical degrees from Northwestern University--including Phi Beta Kappa--and most of my psychiatry residency at
the renown Mount Zion Hospital in San Francisco, where I was selected for the faculty and became Director of Training for Emergency Psychiatry Services.

I am an Assciate Professor at the University of Arkansas for Medical Sciences.

In addition to the usual three [sometimes four] years of psychiatry residency, I took another nine years of half-time training in San Francisco and at the University of Colorado Health Sciences Center in Denver where I have taught psychiatry/advanced psychotherapy as an Associate Clinical Professor. This training has allowed me to qualify for three Board Certifications in psychiatry/ advanced psychotherapy, as well as a tenured faculty position at the Center for Advanced Psychoanalytic Studies, meeting at Princeton.


In Colorado, where I practiced for three decades, the Colorado Board of Medical Examiners and the Colorado Physicians’ Health Program often asked me to evaluate patient complaints about psychiatrists and to treat physicians who are struggling.


In over three decades of practice, I have never been sued for medical malpractice. I have never been censured by any medical organization. I very much hope to use this training and experience to help you.





PAYMENT:

Personal checks
Visa
Master Card

Clinical fees must be paid at time of the appointment.

Forensic Evaluations: One-half of estimated cost is due when evaluation begins with the balance due on presentation of the Report.

Expert Witness Testimony: Estimated cost due prior to deposition or courtroom testimony,
based on charges for one-half day.




jerrysteinmd@gmail.com