SCHEDULING YOUR FIRST VISIT

We will contact you to make your initial appointment after we receive the forms below. The paperwork needed for your first visit can be printed out, completed and:

  • emailed to omason@attention.md
  • faxed to (877) 411-1871
  • mailed to our office.  

If you have the computer skills, the .doc forms can be completed in your word processor.  Please remember to save the completed form in .doc or .pdf format, not in .pages format.

 

Children 12 and under.

Child history form:     Word document     PDF document    

Teacher evaluation form:      Word document      PDF document   We require an evaluation from at least one teacher who knows the student’s capabilities well. 

 

Teenagers 13-17.         

Teen history form:     Word document     PDF document    

Teacher evaluation form:      Word document      PDF document   We require an evaluation from at least one teacher who knows the student’s capabilities well. 

 

College students ages 18-25 years old.            

College history form:     Word document     PDF document   

Parent supplement form:  Word document   PDF document     A history provided by at least one parent is required.  If this is not possible, the forms should be completed by someone who knows the new patient quite well.  

Permission to disclose confidential information to parents  (Word DOC form)  (PDF form)    This allows Attention MD to discuss payment issues, prescription refills and/or ongoing care with parents or guardians.  This is necessary when young adults are carried on their parents' insurance. 

 

Adults 18 and older unless enrolled in college.      

Adult history form:     Word document     PDF document     

Observer supplement form:  Word document   PDF document     A history provided by a spouse or significant other is required.  If this is not possible, the forms should be completed by someone who knows the new patient quite well.

Permission to disclose confidential information to parents:  (Word DOC form)  (PDF form)    This allows Attention MD to discuss payment issues, prescription refills and/or ongoing care with a spouse or parent.  This is necessary when young adults are carried on their parents' insurance or when a significant other will participate in appointment scheduling, prescription refills, etc. . 

 

Release of information

Permission to disclose confidential information  (Word DOC form)  (PDF form)    This allows Attention MD to request past medical history or discuss ongoing care with physicians, therapists, counselors, coaches, school officials, relatives or caretakers.  Each must be listed on the form. 


PAYMENT DETAILS

Our standard is to provide the highest possible level of care at the lowest cost.  We have chosen not to bill or participate with insurance companies and to share the savings with our patients.  We make it very easy for you to bill your own insurance company by providing fully completed HCFA 1500 insurance claim forms at each visit.  These are simply forwarded to your insurance carrier and reimbursement is sent directly to you.  

The costs of initial diagnosis and treatment range from $395 to $520 depending on the level of testing required. Please note that this includes both the complete evaluation and the initiation of treatment.  (Some institutions that provide diagnosis do not include initial treatment in their evaluation.)  

If you would like to ask your insurance company what they reimburse for our services, you can specify the following procedure codes: 

  • Consultation with physician (75 minutes):  99204 (or 90801)
  • Physician evaluation of patient history done prior to the visit:  96101
  • Computerized attention testing:  96120