Milestone Psychiatric &
Psychological Services, P.C.
(Comprehensive Psychiatric & Psychological Services)
PSYCHIATRY
Raja Rao, MD
PSYCHOLOGY
Robert J. Maiden, PhD
Laura A. DeMarco, PhD
Cynthia Dodge, PsyD
Terry Taggart, PsyD
Lynn O’Connell, PsyD
John Cerio, PhD
NURSE PRACTITIONER
Kim Peckham, FNP, NPP in Psychiatry
15 Pleasant St
Linden Oaks Therapy Offices
Hornell, NY 14843
P(607) 324-9240
F(607) 324-9744
100 Linden Oaks, Ste 200
Rochester, NY 14625
P(585) 586-1600 (directions)
P(607) 324-9240 (appointments)
2438 Constitution Ave
112 Park Ave
Olean, NY 14760
P(716) 372-9344
F(607) 372-9497
Wellsville, NY 14895
P(585) 593-1859
F(585) 593-5463
Note to new clients:
Dr. Rao has agreed to see you for an initial evaluation. An initial evaluation does not guarantee that
you will be accepted as a patient. Dr. Rao will decide how to proceed after this consultation, and
based on his findings, a treatment plan will be developed. This includes, but is not limited to; the
acceptance as a new patient, referral to another provider within or out of Milestone.
_______________________________________________
Printed Name
_______________________________________________
Signed Name
1
____________________
Date
MILESTONE PSYCHIATRIC & PSYCHOLOGICAL SERVICES, P.C.
15 Pleasant St  Hornell NY 14843  (607)324-9240  fax (607)324-9744
 112 Park Ave Ste 2  Wellsville NY 14895  (585)593-1859  fax (585)593-5463
 2438 Constitution Ave  Olean NY 14760  (716)372-9344  fax (716)372-9497
 LOTO  100 Linden Oaks Ste 200  Rochester NY 14625  (607) 324-9240  fax (585)586-7951
Authorization for Release of Confidential Information
Patient Name:________________________________________________________ Date of Birth _______/_______/_______
Authorize _____________________________________________ at Milestone PPS, PC: 15 Pleasant St. Hornell, NY 14843
 release information to:  obtain information from:  exchange information with:
Person/organization receiving/communicating the information:
Name: _____________________________________________________________________
Address: ____________________________________________________________________
Phone: _________________________________Fax: _________________________________
Description of Information to be received/disclosed (check all that apply):
• Psychological/social assessment
• Psychiatric evaluation
• Treatment plans
• Progress notes
• Discharge summaries
• Subpoena or legal process
• Worker’s Compensation Claim
• Disability Claim
• Medical history
• Lab/radiology reports
• Juvenile/justice records
• Social services records
• Verbal communication
• Written communication
• Other ___________________
The dates records to be disclosed _______/______/______ TO ____/_____/_____
 ALL
Purpose of release:  evaluation  continuity of care  medication history  other ________________________________
One Time Use/Disclosure: I authorize the one-time use or disclosure of the information described above to the destination identified
herein. My authorization will expire:
 When acted upon
 90 days from this date
 Other: ______________________________________________________________________________
Periodic Use/ Disclosure: I authorize the periodic use or disclosure of the information described above to the destination identified
herein. My authorization will expire:
 When I am no longer receiving services from above identified person/ organization/ facility/ program
 One year from the date signed
 Other: ______________________________________________________________________________
I understand that this authorization is voluntary. Prohibited Disclosure: I understand that my health information may be protected by the Federal
Regulations for Privacy of Individually Identifiable Health Information (Title 45 if the Code of Federal Regulations, Parts 160, and 164) For Alcohol and Drug
Abuse this information is protected by federal l confidentiality rules (42 CFR, Part 2). The federal rules prohibit making any consent of the person to whom it
pertains or as otherwise permitted by 42 CFR, Part 2. A general authorization for the release of medical or other information is not sufficient for this
purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. I understand that I
may revoke this consent at any time except that action has been taken in reliance on it (e.g. probation, parole, etc) and that in any event this consent expires
automatically as described above. I also understand that I may inspect and upon payment of the usual fee, receive a copy of the released information and I
may receive a copy of this consent form. (A copy or facsimile of this authorization shall be as valid as the original).
PROHIBITION ON CONFIDENTIALITY: I understand mental/physical health professionals and teachers must report child sexual/physical abuse and
neglect, threats of suicide and threats of bodily harm to others.
_________________________________________
_____________________________________________
Signature
Parent/Guardian
Date
Date
_____________________________________________
_________________________________________________
Witness
Relationship to patient
Date
2
Milestone Psychiatric &
Psychological Services, P.C.
(Comprehensive Psychiatric & Psychological Services)
PSYCHIATRY
Raja Rao, MD
PSYCHOLOGY
Robert J. Maiden, PhD
Laura A. DeMarco, PhD
Cynthia Dodge, PsyD
Terry Taggart, PsyD
Lynn O’Connell, PsyD
John Cerio, PhD
NURSE PRACTITIONER
Kim Peckham, FNP, NPP in Psychiatry
15 Pleasant St
Linden Oaks Therapy Offices
Hornell, NY 14843
P(607) 324-9240
F(607) 324-9744
100 Linden Oaks, Ste 200
Rochester, NY 14625
P(585) 586-1600 (directions)
P(607) 324-9240 (appointments)
2438 Constitution Ave
112 Park Ave
Olean, NY 14760
P(716) 372-9344
F(607) 372-9497
Wellsville, NY 14895
P(585) 593-1859
F(585) 593-5463
Linden Oaks Patients
Payment for services can be made as follows.
- CASH: you may pay with cash at the time of service and Dr. Rao will give you a receipt.
- CHECK: you may pay by check at the time of service, or mail a check to:
Milestone PPS, PC
15 Pleasant St
Hornell, NY 14843
***please make checks payable to Milestone PPS, PC***
- CREDIT CARD: you may pay with Visa or Mastercard by calling the main office directly
at 607-324-9240 Monday-Thursday 8am-5pm. The patient copy will be mailed the same
day.
3
Milestone Psychiatric &
Psychological Services, P.C.
(Comprehensive Psychiatric & Psychological Services)
PSYCHIATRY
Raja Rao, MD
PSYCHOLOGY
Robert J. Maiden, PhD
Laura A. DeMarco, PhD
Cynthia Dodge, PsyD
Terry Taggart, PsyD
Lynn O’Connell, PsyD
John Cerio, PhD
NURSE PRACTITIONER
Kim Peckham, FNP, NPP in Psychiatry
15 Pleasant St
Linden Oaks Therapy Offices
Hornell, NY 14843
P(607) 324-9240
F(607) 324-9744
100 Linden Oaks, Ste 200
Rochester, NY 14625
P(585) 586-1600 (directions)
P(607) 324-9240 (appointments)
2438 Constitution Ave
112 Park Ave
Olean, NY 14760
P(716) 372-9344
F(607) 372-9497
Wellsville, NY 14895
P(585) 593-1859
F(585) 593-5463
Client: _________________________________________________________________________________
Last Name
DOB: _____/_____/_____
First Name
Social Security # _______-_____-_______
Middle Initial
Sex:
M ____ F ____
Address: __________________________________________ PO Box ________________________
Street
____________________________ __________________ _______________
City
State
Zip Code
Home Phone: (_____) _______________
Can we leave a message? YES
______ NO ______
Work Phone: (_____) ______________
Can we leave a message? YES
______ NO ______
Cell Phone: (_____) _______________
Can we leave a message? YES
______ NO ______
Employer: ________________________________ Student: ____ Not Employed: ____
Primary Care Physician: _______________________________ Phone: ____________________
Pharmacy Name/ Phone:____________________________________________________________
Emergency Contact: _______________________________________________________________
Relationship to patient: _____________________________________________________________
Phone: ___________________________________________________________________
4
Patient Name: ______________________________________ DOB: ________________________
Presenting Problem:
What is the main concern that leads you to consult us?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Psychiatric and Psychological History:
Provide all past mental health and substance abuse treatment, including outpatient and inpatient.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Medication History:
List all current and past psychiatric medications:
DRUG
DOSE
FREQUENCY
PRESCRIBING PHYSICIAN
________________________________________________________________
________________________________________________________________
________________________________________________________________
List current medications other than psychiatric:
DRUG
DOSE
FREQUENCY
PRESCRIBING PHYSICIAN
________________________________________________________________
________________________________________________________________
________________________________________________________________
List any non-prescription medications:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Medical and Surgical History—Past/Present
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Social History
Marital status:
Single ___ Married ___ Widowed ___ Divorced ___ Separated ___ Partnered ____
Name: ___________________________________________________________________________
Children
Name
Age
Location
Custody (Joint/ Single, etc)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Pertaining to children who will be seen:
Lawyer:______________________________________ phone:______________________________
Law Guardian: ________________________________ phone: ______________________________
School Counselor: _____________________________ phone: _______________________________
5
Milestone Psychiatric &
Psychological Services, PC
Patient Name: ______________________________________ DOB: ________________________
Financial Policy
We are dedicated to providing the best possible care for you, and we want you to completely
understand our payment policies.
1.
Insurance: We participate in most insurance plans, including Medicare. If you are insured by a
plan we do business with but do not have an up-to-date insurance card, payment in full for each
visit is required until we can verify your coverage.
2.
Co-payments and Deductibles: All co-payments and deductibles must be paid at the time of
service. This arrangement is part of your contract with your insurance company. For your
convenience we accept MasterCard and Visa. You will be billed a $10 handling fee for not
paying your co-pay at the time of service unless other arraignments have been made.
3.
Non-covered Services: Be aware that some and perhaps all of your services you receive may be
non-covered or not reasonable or necessary by Medicare or other insurers. You must pay for
these services in full at the time of your visit.
4.
Proof of Insurance: All patients must complete out patient registration form before being seen.
We must obtain a copy of your current valid insurance card to provide proof of insurance. If
you fail to provide us with the correct insurance information in time to meet your
insurance company claim filing limit, you will be responsible for the balance of the claim.
5.
Claims Submission: We will submit your claims and assist you in any way we reasonably can
to help you get your claims paid. Your insurance company may need you to supply certain
information directly. It is your responsibility to comply with their request. Please be aware that
the balance of your claim is your responsibility whether or not your insurance company pays
your claim. Your insurance benefit is a contract between you and your insurance company; we
are not party to that contract.
6.
Coverage Changes: If your insurance changes, please notify us so we can make the appropriate
changes to help you receive your maximum benefits. If your insurance company does not pay
your claim in 45 days, the balance will automatically be billed to you.
7.
Non-payment: If your account is over 30 days past due, you will receive a letter stating that
you have 30 days to pay your account in full. Partial payment will not be accepted unless
otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your
account to a collection agency and you and your immediate family members may be
discharged from this practice. If this is to occur, you will be notified by regular and certified
mail that you have 30 days to find alternate medical care.
8.
NO SHOW Fees: The number of patients requiring services dictates the use of time
responsibly. Please be advised of the institution of a no show fee for failure to come to a
scheduled appointment without at least 24 hours prior notice with the exception of an
emergency. This fee cannot be billed to an insurance company and is due prior to your next
appointment. We reserve the right to not reschedule future appointments.
PsyD/ PhD
$40 (20-30 min)/ $80 (37-50 min)
MD/ FNP
$50
Milestone Psychiatric &
6
Psychological Services, PC
Patient Name: ______________________________________ DOB: ________________________
Professional Fees
The fee for an initial visit is $230. Subsequent 37-50 minute sessions are $166, and 20-30 minute
sessions are $103, and medication management visits are $92. You may be eligible for a sliding-scale
self-pay rate, please inquire with the receptionist.
Professional services that you may request and/or require, including written reports, consultation with
other professionals (with your informed consent), and telephone, fax, and/or e-mail communications
which become excessive and beyond the scope of reasonable services, will be billed at $161.25/hour
accrued in 15 minute intervals.
If you become involved in legal proceedings that require participation, you will be expected to pay for
all professional time, including preparation, travel, and attendance at any legal proceeding. Due to the
complexity of legal proceedings and time away from client hours, the hourly rate is $215, accrued in
15 minute intervals.
Occasionally, it may be advisable to administer self-report rating scales and/or other social-emotional
and psychological measures. You should be aware that your insurance company may not cover the
cost for the administration and scoring of these assessment measures. In addition, psycho educational
assessments may not be covered by your insurance company. Rates for these types of psychological
testing are generally $174.00 per unit. Specifics and financial arrangements should be discussed prior
to service.
Our practice is committed to providing the best treatment to our patients. Our fees are representative of
the usual and customary charges for our area. Let us know if you have any questions or concerns.
I have read and understand the Financial Policy and Professional Fees and agree to
abide by these guidelines:
___________________________________________________________________________
Signature of patient (or responsible party, if minor)
Date
Prescription Refill Policy
When you have a prescription that needs to be refilled, please do the following:
1. Please call the office at least 7 -10 days in advance. Failure to do so may result in you not
getting your prescriptions filled in a timely manner.
ALL prescriptions need approval from Dr Rao/ Kim Peckham before they can be
obtained.
2. Please have all applicable information ready for the receptionist when calling (prescription
name, pharmacy, etc).
_________________________________________________________________________________
Signature of patient/ responsible party
Date
7
Milestone Psychiatric &
Psychological Services, PC
Patient Name: ______________________________________ DOB: ________________________
Informed Consent for Treatment
Clinical records are kept under the strictest rules of confidentiality, which means that information about
your treatment will not be releases to any outside agency or individual without your written permission.
Please be advised, however, that rules of confidentiality will be broken under certain circumstances as
described in the NOTICE OF PRIVACY PRACTICES below. Please do not hesitate to ask questions.
Entering mental health treatment is a courageous step. You should know that sometimes symptoms
become worse before they become better, though this should subside as the work of treatment progresses.
You may be asked to participate in activities and tasks outside the sessions held here. While you have the
right to refuse any therapeutic technique, we must be able to discuss your thoughts and feelings about
treatment. You will be involved in the process of designating and implementing, and the periodic review,
of your treatment plan. You have the right to be informed of your mental health diagnosis after the mental
health assessment is completed, and the purpose of any prescribed medication and potential side effects.
You also have the right to withdraw consent and terminate services at any time. If you have any questions
about the nature if your treatment, talk directly to the doctor you are seeing as soon as the question arises.
I authorize Milestone PPS, PC to release given info to my listed insurance company, information from my
records relating to the identity, diagnosis, and treatment for the purposes or needs of payment.
__________________________________________________________________________________________
Signature of patient/ responsible party
Date
HIPAA
I have reviewed the HIPAA privacy statement.
_____________________________________________________________
Signature of patient/ responsible party
Date
8