Cornerstone Psychiatric Services, Inc.

1790 E. Venice Ave. Ste. 204
Venice, FL 34292
 

Phone: (941) 488-8884

Fax: (941) 488-5554

Medical Records Fax:

(941) 375-0119

Upload Documents

Do you have updated insurance?

Do you have some lab results to share with your provider?

Did you forget to upload your ID and Insurance card(s) in the Online New Patient form?

 

Use this Upload document feature to send us these items and any other documents you care to share with us.  

Use this to send us documents such as:

* Paper form of Patient Registration Form

* Photo ID

* Insurance Cards (front & back sides)

* Prescription Drug Benefit card (front & back)

* Medication List

* Lab results

* Medical Records from other providers

* other documents 

Upload Documents

Additional Patient Forms 

Release of Information (ROI)

Who needs to complete this form? See the reasons below:
1.) All new patients, we suggest and encourage you to complete this form for your Primary Care Physician (PCP) and your previous mental health provider(s). One form per provider. Complete additional Online forms or Print additional copies to include your spouse or any individual(s) you allow to be able to call our office and ask/discuss information relating to your appointments, prescriptions and treatment.

2.) If you have recent lab order results from your PCP, please complete with your PCP contact information.

3.) If you have been asked by our office staff to complete this form.

Online Form - Medical Records Release of Information

Medical Records Release of Information

Preferred Method to complete HIPAA Authorization to Use and Disclose Form 

Complete Now

or Paper Form

Medical Records Release of Information

Alternate method instead of online version, you can click on Download Now button to print and hand write your responses. Then mail back to our office or drop it off at our office.

Download Now
Download
Authorization to Release of Information (ROI)
Authorization to Release Information v07[...]
Adobe Acrobat document [215.9 KB]

Additional Documents:

(Optional forms that you can complete or you may be asked by our staff to complete)

Download
Psychiatric only Medication List
You can use this form for your list of Psychiatric related medications to add to your New Patient Registration form OR if you have been asked by the Cornerstone Psychiatric staff to complete this form.
Medication List - Psychiatric onlyx.pdf
Adobe Acrobat document [153.8 KB]
Download
Complete Medication List
This document you can print and complete to provide us your complete list of medications, vitamins, herbal supplements and any other over-the-counter products.
Medication Complete List-v0424.pdf
Adobe Acrobat document [146.0 KB]
Download
Patient Demographic Update Form
Download and complete this form if you have any any change of name, address, phone and/or insurance/financial responsibility. Mail back to our office or bring it in at your next appointment.
Patient Demographic Update Form V0724.pd[...]
Adobe Acrobat document [200.6 KB]

Online Form - Patient Demographic and Medication List

 

Preferred Method for completing

 

Required for previous patients that have not been seen in 1 to 2 years ago. You can also upload your updated insurance card(s) in this form as well.

Complete Demographic / Medication List Update Form Now

Online Form - Controlled Substance Agreement (CSA)

 

Preferred Method for completing

 

Required for new patients currently on a controlled substance (Schedule II, III, IV and V) and current patients that have been asked to complete this form.

Complete CSA Now
Download
or PAPER FORM - Controlled Substance Agreement (CSA)
Required for new patients currently on a controlled substance (Schedule II, III, IV and V) and current patients that have been asked to complete this form.
Controlled Substance Contract Agreementv[...]
Adobe Acrobat document [119.1 KB]
Download
Adult ADHD Self-Report Scale (ASRS v1.1)
Complete this form only if you have been asked to by Cornerstone Psychiatric OR if you have been diagnosed with Adult ADHD already, please complete this form and bring with you at your first appointment. The Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist was developed in conjunction with the World Health Organization (WHO), and the Workgroup on Adult ADHD that included the following team of psychiatrists and researchers:
• Lenard Adler, MD, Associate Professor of Psychiatry and Neurology
New York University Medical School
• Ronald C. Kessler, PhD, Professor, Department of Health Care Policy
Harvard Medical School
• Thomas Spencer, MD, Associate Professor of Psychiatry
Harvard Medical School
ADHD-ASRSv1.1x.pdf
Adobe Acrobat document [545.3 KB]

DISCLAIMER: This screening tool is used to provide clinical support at the point of care. The questionnaire is meant to be completed by a patient to help facilitate communication with a care team in a medical office environment. It is not a diagnostic instrument and is to be used solely within the context of medical treatment with a physician/nurse practitioner or other health care provider.

Download
Patient Health Questionnaire (PHQ-9)
If you have been asked by your clinician to complete this form, please print and complete this PHQ-9 form and bring it with you at your next appointment.
DISCLAIMER: This screening tool is used to provide clinical support at the point of care. The questionnaire is meant to be completed by a patient to help facilitate communication with a care team in a medical office environment. It is not a diagnostic instrument and is to be used solely within the context of medical treatment with a physician/nurse practitioner or other health care provider.
PHQ-9_CPS.pdf
Adobe Acrobat document [569.5 KB]
Download
Generalized Anxiety Disorder Screener (GAD-7)
If you have been asked by your clinician or office staff to complete this form, please print and complete the GAD-7 screener tool form and bring it with you at your next appointment.
DISCLAIMER: This screening tool is used to provide clinical support at the point of care. The questionnaire is meant to be completed by a patient to help facilitate communication with a care team in a medical office environment. It is not a diagnostic instrument and is to be used solely within the context of medical treatment with a physician/nurse practitioner or other health care provider.
GAD7 Form.pdf
Adobe Acrobat document [324.0 KB]
Download
Mood Disorder Questionnaire (MDQ)
If you have been asked by your clinician or office staff to complete this form, please print and complete the MDQ screener tool form and bring it with you at your next appointment.
DISCLAIMER: This screening tool is used to provide clinical support at the point of care. The questionnaire is meant to be completed by a patient to help facilitate communication with a care team in a medical office environment. It is not a diagnostic instrument and is to be used solely within the context of medical treatment with a physician/nurse practitioner or other health care provider.
MDQ.pdf
Adobe Acrobat document [491.1 KB]
Download
Binge Eating Disorder Screener-7 (BEDS-7)
This tool was developed by Shire US Inc. and is intended for screening use only. It is not used as a diagnostic tool; and is for adults only.
BEDS-7-BingeEatingDisorder.pdf
Adobe Acrobat document [72.1 KB]

Only for use by current active patients of Cornerstone Psychiatric

Once we receive your Prescription Refill request, we will do our best to send your refill to selected pharmacy by end of business day as long as your refill is due.

 

Please avoid from calling the office multiple times for status of your refill request.

 

We kindly ask that you check with your pharmacy on the status of your refill order. 

 

Important Note: We only respond to this online rx refill request Monday - Thursday: 8:00 a.m.-4:00 p.m. and Friday 8:00 a.m. - 11:00 a.m. 

Rx Refill Request
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