New Patient Inquiry
This form has been created using a HIPAA-compliant version of Google Forms. Please answer each question as accurately as possible. If eligible, you will be contacted to schedule a more in-depth screening call. The calls usually take place on Fridays, because Dr. Khan sees patients on Monday-Thursday.
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Email *
How did you find Dr. Khan's name? If you were referred by a specific person, please provide that person's name and your relationship to them. *
Name and Pronouns of Person Filling Out This Form *
Phone Number (xxx-xxx-xxxx) *
Relationship to Patient *
In order to improve access to care for marginalized populations, Dr. Khan works with two specific age groups: People who are 3-17 years old (regardless of race, gender, sexuality, etc) and people aged 18-32 y/o who are BIPOC, LGBTQIA2S+, autistic, and/or seeking an autism evaluation. Which group does the patient fall into? If multiple groups apply, you only need to pick one. *
Patient's Name (if not above)
Patient's Gender *
Patient's Pronouns *
Patient's Date of Birth *
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Patient's Location (City & State). Dr. Khan can only work with Maryland residents who are physically located in Maryland. She cannot do telehealth with anyone located in DC, Virginia, or any other state. *
Requested services (check all that apply - Dr. Khan does not offer weekly therapy). *
Required
Reason for seeking treatment: *
Previous diagnoses: *
Are there any related medical issues or concerns? *
Current Medications (prescription, over the counter, vitamins, and supplements) *
Primary Insurance *
Required
Secondary Insurance *
This question does NOT apply to individuals who are only seeking an independent evaluation for gender affirming surgery. Dr. Khan is currently unable to evaluate or treat individuals who have Medicare or Medicaid, regardless of any other insurance coverage they have. Does the patient have Medicare or Medicaid? *
Member ID (if Carefirst, BCBS, or Anthem) - INCLUDE THE LETTERS that come before the numbers. Don't include spaces. *
Group ID (if Carefirst, BCBS, or Anthem) *
For those with Carefirst/BCBS/Anthem, does your policy require authorization for office-based or virtual psychiatric services (CPT code examples = 90792, 99205, 99214)? *
Is self-pay okay? *
Does the patient have out-of-network benefits with their health insurance? *
Preferred Location (not guaranteed). Dr. Khan's office is in Laurel, just off the interchange between I-95 and Route 200. *
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