Khan Psychiatry

Personal Information

Gender *
Emergency Contact Relationship *

Medical History

Are you taking any prescription medications and/or over-the-counter supplements? *
Do you have or have you ever had any of the following:

Insurance Information

Insurance Company Name (list contains the companies our outpatient clinic accepts) *
Policy Holder Relationship to Patient



I understand that if I am “dismissed” from the practice, it means I can no longer schedule appointments, get medication refills or consider Khan Psychiatry to be my treating physician. I will have to find a doctor in another practice.

Common Reasons for Dismissal (not an inclusive list): Failure to keep appointments, frequent no-shows; Noncompliance (you do not follow physician instructions for treatment and/or with prescribed medications); Abusive to staff ; Failure to pay my bill. Khan Psychiatry will send a letter to my last known address, via certified mail, notifying me that I am being dismissed. If I have a medical emergency, I understand that I will need to seek treatment for the nearest emergency room. Khan Psychiatry will forward a copy of my medical record to my new doctor after I have let them know who it is and they've received a proper HIPAA compliant release form.



Financial Policies

I understand that payment is due at the time services are rendered.
I understand that I may request a payment plan if I am unable to pay my balance in full at the time the service is rendered because: (1) I am a private pay patient; or (2) I have insurance, and I am subject to a deductible and/or co-insurance amount that I cannot afford to pay in full. 
I understand that I must request a payment plan with Khan Psychiatry. I understand that half of my balance for the services rendered will be due at that time, and the remaining balance can be split into two (2) payments, with the first payment being due two (2) weeks later and the final payment two (2) weeks after that. 

Private Pay: Payment is due at the time of service being rendered.

Insurance: Although Khan Psychiatry is contracted with several insurance companies, it is my responsibility to make sure that their physicians are in my plan and to know my insurance benefits. At the time of service, I am responsible for all fees that are not covered by my insurance, including co-pays, co-insurance, deductibles and non-covered services or items received. The co-pay cannot be waived by Khan Psychiatry, as it is a requirement placed on me by my insurance carrier. Khan Psychiatry strives to be as accurate as possible in calculating my responsibility but, with so many variations in policies and fee schedules, they are not always exact. In addition to an Explanation of Benefits (EOB) from my insurance company, I may receive a statement from Khan Psychiatry for any balance due. I understand that it is my responsibility to notify Khan Psychiatry if I have a change in insurance. Our Insurance Update Form is located on our website, under the "forms" tab. Please notify us via email or text when you have completed our Insurance Update Form.

For my convenience, Khan Psychiatry accepts cash, checks, and credit cards. I understand that I must keep a credit/debit card on file with Khan Psychiatry. Payments are also accepted by phone. There will be a $35 charge assessed for any check returned by my bank for any reason.

I understand that I will be charged a Late Cancellation fee of $75 for failing to call and cancel at least 24 hours prior to my scheduled appointment. If I am experiencing an emergency, I will provide as much notice as possible to avoid being charged the Late Cancellation fee; and in those instances, a decision will be made on a case-by-case basis while taking into account my history of late cancellations.
I understand that I will be charged a No Show fee of $150 for failing to call and failing to show for my scheduled appointment.
I understand that Late Cancellation and No Show fees will be automatically charged to my card on file. I understand that if this card is declined for a Late Cancellation or No Show fee, a second attempt will be made the following business day. If it is declined again, Khan Psychiatry will not allow me to schedule an appointment nor provide medication refills until I fulfill this financial responsibility. If payment for these fees is not received within 30 calendar days, Khan Psychiatry reserves the right to terminate the physician-patient relationship with me and I will need to find a new provider.
I understand that these fees are not billable to insurance.
I understand that if I late-cancel, miss or no show, for whatever reason, to more than 3 appointments in one calendar year, Khan Psychiatry reserves the right to terminate the physician-patient relationship with me and I will need to find a new provider.
I understand that my card on file will also be used for payment of services (co-payment, deductibles, and fees) that are due at the time services are rendered.
I understand that if I wish to utilize another form of payment, I must notify Khan Psychiatry immediately before or after my services were rendered.
I understand that if I have an active payment plan [for an outstanding balance] with Khan Psychiatry, my card on file will automatically be charged on the agreed upon dates. For payment plans, I understand that if my card is declined, a second attempt will be made the following business day. If it is declined again, Khan Psychiatry will not allow me to schedule an appointment nor provide medication refills until I fulfill this financial responsibility. I understand that account payment in full will be due within 30 calendar days and I will no longer be eligible for any future payment plans. If payment in full is not received within 30 calendar days, Khan Psychiatry reserves the right to terminate the physician-patient relationship with me and I will need to find a new provider.
I understand that Financial Hardships will be taken into account on a case-by-case basis.



Late Cancellation fee is $75 and No Show fee is $150
Completion/Preparation of Reports at a rate of $150.00 per hour, with a $75.00 minimum
Legal testimony at a rate of $400.00 per hour (to include travel time)


Disability, Insurance, Attending Physician Statements, FMLA, Letters

Completion of forms/letters, including but not limited to: short or long term disability insurance, FMLA, life insurance, forms requesting special accommodations at work/school will be billed a rate of $30 per occurrence
Certain forms, such as FMLA, will require an appointment prior to completion. 

Payment is due prior to the completion of these forms. Once payment has been received, please allow up to 14 days for completion. 



Medical Records

We will provide you with a copy of your medical records upon request and for a fee. You will need to sign a letter of release prior to having them copied.

Allow 30 days for any medical records request to be processed.

Copying/scanning of your file, at your request (for the purposes of sharing with your attorney, CPS, school, employer, etc.), per LA RS 40:1165.1, will be charged a $25.00 handling fee, plus $1.00 for the first 25 pages, $0.50 for pages 26-350, and $0.25 each page thereafter. Additionally, if this must be mailed, you will be responsible for the actual amount of postage. 

This fee must be paid IN FULL prior to this service being rendered.




If I receive a bill from Khan Psychiatry, it is because they believe the balance is my responsibility. Your statement will come from Physician Billing Inc in Slidell, LA. 

I should contact my insurance company first, if I think there is a problem.

If I have any questions about my bill, I will contact Khan Psychiatry's billing department at the phone number listed on the bill. (985.781.0548)

If I cannot pay my entire balance, I must call to make payment arrangements.

Accounts that are not paid within 60 days begin an in-house collection process. If my balance becomes 90 days old, my doctor will be notified, and I may be subject to dismissal from the practice.


updated 01/01/2023

I acknowledge that I have received and read a copy of the Khan Psychiatry Policies. * 🛈

Prescription Refill & Mail Order Pharmacy Policies

Unless otherwise directed by your doctor, maintenance medications will usually be approved if the patient has had an office visit within the last 3 months. YOU ARE RESPONSIBLE FOR KNOWING WHEN YOU NEED A REFILL.

If a patient has not been evaluated in 3 or more months, a follow up visit will be needed to verify medication needs.

Our office does NOT recieve refill requests from pharmacies. ALL refills must be requested by the patient, using our online refill request form. 

Certain medications may require laboratory testing before they can be refilled.

No prescriptions will be refilled when the office is closed, on weekends or on holidays.

● As we are only in clinic one day each week, refill request forms MUST be completed 3-4 days prior to your last dose. 

● The Refill Request Form MUST be used for EVERY refill request.

Refills can only be authorized on medications prescribed by doctors in our office. We will not refill medications prescribed by other doctors.


Mail Order Prescription Refills:

If you use a mail order company, please contact us 2 to 3 weeks before your medication is due to run out.

● If your doctor determines that you need to start a medication immediately, we will give you a written prescription to use locally, in addition to the one you should mail to the mail order pharmacy.

Controlled substance are medications that have the potential for abuse, addiction and dependence, Federal and State laws have strict guidelines for prescribing them. Additional refill rules and policies apply to ALL controlled substances.

The most restricted medications are called “Schedule II” and include medications such as Ritalin, Adderall, Concerta, Vyvanse, etc. These must be on a written prescription and can only be dispensed 30 days at a time with no refills. This means that a new prescription must be given every 30 days (this is not technically a refill, but a new prescription).

Other controlled substances such as benzodiazepines, like Klonopin, and some medications for insomnia, like Ambien, may be called in by the doctor and may have refills. A patient who has been prescribed these medications is required to visit their physician every 3 to 6 months (depending on what your doctor recommends) for monitoring purposes. Between appointments, we will be able to refill the prescriptions on a monthly basis.

*** NO early refills will be granted if medications are overused, abused, misused, lost or stolen. ***

In the case of lost or stolen medications a copy of a police report may be required.

In the case of long-term use of a Controlled Substance medication we may require that a Controlled Substance Agreement (an agreement about policies between the practice and the patient) be signed by the patient. Violation of this Agreement by the patient may result in the patient being asked to find medical care elsewhere (discharged from the practice). This Agreement will include requirements such as using the same pharmacy every time and not getting the medication from other doctors.

For stimulant medications the patient will need to contact the office to request a refill, allowing at least 3 business days for us to process the request. The patient or an immediate family member designated by the patient must pick up the prescription. We cannot give a controlled substance prescription to any other individual without written permission from the patient. Any individual picking up the prescription on behalf of the patient will be required to show some form of photo ID.

Thank you for your consideration and cooperation.

I acknowledge that I have read and understand the Prescription policies of Khan Psychiatry * 🛈

Consent to Treat

This document contains important information about this practice and its business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law designed to protect your privacy and your rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with the attached Notice of Privacy Practices that explains HIPAA and how it affects you. The law also requires that we obtain your signature acknowledging that you have received this information. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can address any questions you have about the procedures before your next session. When you sign this document, it will also represent an agreement between you and Khan Psychiatry. You may revoke this Agreement in writing at any time. That revocation will be binding except for information already disclosed; obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.

MENTAL HEALTH AND CONSULTATION SERVICES. Services vary depending on your needs, and your psychiatrist's approaches. Aside from treatment with medications there are many different methods used to deal with the issues that you hope to address. Your initial session(s) will involve an evaluation of your needs. By the end of the evaluation, your psychiatrist will be able to offer you some first impressions about indication for medication and what your work would include along with a plan to follow, if you decide to continue with our services. You should evaluate this information along with your own impression of whether you feel comfortable working with your provider. Treatment/consultation involves a commitment of time, money, and energy, so you should be careful about the provider you select. If you have questions, please feel free to discuss them whenever they arise.

LIMITS ON CONFIDENTIALITY. The law protects the privacy of all communications between a patient and a psychiatrist. Several types of communications and the consent they require are discussed below.

1. Generally, information about your treatment can be released to others only if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA.

2. There are other situations, however, that require only that you provide written, advance consent.

Your signature on this Agreement provides consent for the following:

● Your psychiatrist may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing your identity. The other professionals are also legally bound to keep the information confidential. You will not be told about these consultations unless your therapist feels that it is important to your work together. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.

● If your psychiatrist believes that a patient presents an imminent danger to his/her health or safety, they may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection.

There also are some situations where psychiatrists are permitted or required to disclose information without either your consent or Authorization:

● If you are involved in a court proceeding and a request is made for information concerning the professional services that are provided to you, such information is protected by the psychiatrist-patient privilege law. Information cannot be provided without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.

● If a government agency is requesting the information for health oversight activities, we may be required to provide it for them.

● If a client files a complaint or lawsuit against a psychiatrist, that psychiatrist may disclose relevant information regarding that patient/client in order to defend him/herself.

In addition, there are some situations in which we are legally obligated to take actions, which are necessary to attempt to protect others from harm and which may require revealing some information about a patient’s treatment. These situations are unusual in this practice. They include the following:

● If there is cause to suspect that a child under 18 is abused or neglected, or reasonable cause to believe that a disabled or elderly adult is in need of protective services, the law requires that a report be filed with the County Director of Social Services. Once such a report is filed, additional information may be required.

● If there is reason to believe that a client presents an imminent danger to the health and safety of another, we may be required to disclose information in order to take protective actions, including initiating hospitalization, warning the potential victim, if identifiable, and/or calling the police. If such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit disclosure to only what is necessary.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that any questions or concerns that you may have now or in the future be discussed. The laws governing confidentiality can be quite complex. In rare situations where specific advice is required, formal legal advice may be needed.

E-MAIL, CELL PHONE, AND FAX COMMUNICATION. It is very important to be aware that e-mail and cell phone (also cordless phone) communication can be relatively easily accessed by unauthorized people and, hence, the privacy and confidentiality of such communication can be easily compromised. Emails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Faxes can be sent erroneously to the wrong address. Please notify our office at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices. Please do not use e-mail or faxes in emergency situations!

PROFESSIONAL RECORDS. You should be aware that, pursuant to HIPAA, your psychiatrist may keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking treatment, a description of the ways in which your problem impacts your life, your diagnosis, medications prescribed, type of therapy approach provided, the goals that are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records received from other psychiatrists/psychologists/therapists, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless such other person is a health care provider) and your psychiatrist believes that access is reasonably likely to cause substantial harm to such other person or to yourself, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, it is recommended that you initially review them with your psychiatrist or have them forwarded to another mental health professional so you can discuss the contents. (There may be a charge for copying records). The exceptions to this policy are contained in the attached Privacy Notice. If your request for access to your records is refused, you have a right of review, which will be discussed with you upon request. In addition, your psychiatrist may also keep a set of Psychotherapy Notes. These Notes are for your psychiatrist’s use and are designed to assist in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of your conversations with your psychiatrist, an analysis of those conversations, and how they impact on your therapy. They may also contain particularly sensitive information that you may reveal to your therapist that is not required to be included in your Clinical Record and information revealed to your therapist confidentially by others. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without a separate written, signed Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal to provide it.

PATIENT RIGHTS. HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that your psychiatrist amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to view and copy your records,. Your psychiatrist will be happy to discuss any of these rights with you. These rights are explained further in the Privacy Notice.

I acknowledge that I have read the Consent to Treat and I authorize Khan Psychiatry to be my treating provider. * 🛈

Privacy Notice


Policies and Practices to Protect the Privacy of Your Health Information



I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Your protected health information (PHI) may be disclosed for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

● "PHI" refers to information in your health record that could identify you.

● "Treatment, Payment and Health Care Operations"

○ Treatment is the provision, coordination or management your health care and other services related to your health care. An example of treatment would be consultation with another health care provider, such as your family physician or another psychologist.

○ Payment is obtaining reimbursement for your healthcare. Examples of payment are when your health information is disclosed to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

○ Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

○ "Use" applies only to activities within this practice such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

○ "Disclosure" applies to activities outside of this practice group, such as releasing, transferring, or providing access to information about you to other parties. obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when information for purposes outside of treatment, payment and health care operations is requested, your authorization will be obtained before releasing this information. You have the right to restrict certain disclosures of PHI to health plans/insurance companies if you pay out of pocket in full for the health care service. "Psychotherapy notes" are kept separate from the rest of your medical record. These are notes made by your provider about your conversation during an individual, group, couple, or family counseling session, and are given a greater degree of protection than your general record. They cannot be released on a general Authorization request for your medical record. Most uses and disclosures of psychotherapy notes, any uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI require patient authorization. Other uses and disclosures not described in the Privacy Notice will be made only with the authorization of the individual.

You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization (1) after information has been released or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

II. Uses and Disclosures with Neither Consent nor Authorization

Your health information may be used or disclosed without your consent or authorization in the following circumstances:

● Child Abuse: If you give information which leads your physician to suspect child abuse, neglect, or death due to maltreatment, that information must be reported to the county Department of Social Services. If asked by the Director of Social Services to turn over information from your records relevant to a child protective services investigation, your physician must do this.

● Adult and Domestic Abuse: If you provide information that gives your therapist reasonable cause to believe that a disabled adult is in need of protective services, this must be reported to the Director of Social Services.

● Health Oversight: The Louisiana Medical Board, has the power, when necessary, to subpoena relevant records should your provider be the focus of an inquiry.

III. Uses and Disclosures for Treatment, Payment, and Health Care Operations

Your protected health information (PHI) may be disclosed for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

● Judicial or Administrative Proceedings: If you are involved in a court proceeding, and a request is made for information about the professional services provided to you and/or the records thereof, such information is privileged under state law, and must not be released without your written authorization, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

● Serious Threat to Health or Safety: Your confidential information may be disclosed to protect you or others from a serious threat of harm by you.

IV. Patient's Rights and Physician’s Duties

Patient's Rights:

● Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). If you wish, the office will discuss with you the details of the accounting process.

● Right to a Paper Copy - You have the right to obtain a paper copy of this notice upon request, even if you have agreed to receive the notice electronically.

● Right to Request Restrictions -You have the right to request restrictions on certain uses and disclosures of PHI about you, including restricting a disclosure to a health plan for purposes of carrying out payment or health care operations (not treatment) and the PHI pertains solely to an item or service for which the provider has been paid in full. Your request must describe in detail the restriction you are requesting. While we make every effort to honor your request, it may not be possible.

● Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing someone. If you request it, your bills may be sent to another address.)

● Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of health information in the mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your therapist may deny your access under certain circumstances, but in some cases, you may have this decision reviewed. On your request, your therapist will discuss with you the details of the request and denial process.

● Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your therapist may deny your request. If you wish, your therapist will discuss with you the details of the amendment process.

Each of the above rights may be exercised through a written request signed by you or your representative.

Provider’s Duties:

● Your provider is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.

● Your provider reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, the current terms will apply.

● Your provider is required to notify you following a breach of your unsecured PHI.

● If policies and procedures are revised, you will be informed by mail of these revisions prior to any release of PHI.

V. Complaints

If you are concerned that your privacy rights have been violated, or you disagree with a decision about access to your records, you may file a written complaint via postal mail:

Khan Psychiatry, 778 Chevelle Drive, Baton Rouge, Louisiana 70806

Tel.: 225-953-8250

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services in Washington, DC within 180 days of an alleged violation of your rights.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on January 1, 2016 (updated 01/01/2023)

If we make material changes to our privacy practices, we will provide copies of revised notices to all active clients. Copies of our most recent notice may be obtained by contacting Khan Psychiatry at the above address.