Registration and Billing Forms (for all new intakes: please complete #1-4, and either #5 or #6 depending on your situation and submit before your first appointment) (Tip: If you are trying to complete the forms using your phone, there may be PDF fill and sign apps which may allow you to do this)
- CAPP Client Data Sheet (contact information – please sign where indicated: NOTE: HIPAA statements provided below and Dr. Takeuchi is licensed by the Medical Board of California as per notice at bottom of the page)
- Office Policy (please sign at the bottom; rates subject to change)
- Health History Questionnaire (for initial intake)
- Payment by Credit Card Authorization (for monthly balances, co-payments, costs not covered by Aetna or MHN if we bill them)
- Financial Responsibility Agreement – private pay ( for those paying out-of-pocket for services) OR
- Financial Responsibility Agreement – insurance (for billing Aetna, MHN only if you have a current plan with them that covers Dr. Takeuchi; CAPP does not bill other insurance companies)
- Only if you are a Medicare patient: You will need to complete a Medicare Private Contract in order to see the doctor as a private pay client as Dr. Takeuchi does not bill Medicare (see below under Miscellaneous Forms)
Please check out the Open Payments database notice at the bottom of this page.
Authorization for Release of Information Forms
Release of Info Form (allows your doctor to share information with specified person or entity such as a relative, teacher or former, current or new provider if you wish)
Request for Transfer of Medical Records (allows your doctor to send your records to a specified person, usually another provider)
Billing Forms
(see #4-6 above to update forms such as when your insurance coverage changes or when you wish to use a different credit card)
Health Information Privacy Practices (HIPAA)
CAPP Notice of Health Information Privacy Practices (FYI – to read about CAPP’s privacy policy)
CAPP Privacy Statement (FYI – additional info on HIPAA and our privacy/confidentiality policy)
Miscellaneous Forms and Screening Tools
Medicare Private Contract (only if you are a Medicare patient and wish to pay privately as Dr. Takeuchi is opted-out of and does not bill Medicare)
Patient Safety Plan (this may need to be completed in certain situations)
Patient Health Questionnaire (PHQ-9) (for some intake situations) – depression assessment tool; 2 versions: Adult version & Adolescent version
GAD-7 – quick screening tool for anxiety (for those being evaluated for anxiety)
Adult ADHD Self-Report Scale – a self-assessment tool for adults
NICHQ Vanderbilt Assessment Scales – an ADHD assessment tool on the NICHQ website (for some evaluations)
Open Payments Database Notice
As required by law, you as a patient should be made aware that The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public
NOTICE TO PATIENTS
Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov,
email: licensecheck@mbc.ca.gov,
or call (800) 633-2322.