New Patient Registration Steps

1) Read Welcome Letter and check insurance plans we accept

2) Pay your Initial Visit Deposit of $60.00

3) Complete Online Authorization to Use and Disclose (Medical Records Release of Information) Form

4) Complete Online New Patient Registration Form

You must complete ALL 4 steps before we will call you to schedule the appointment.

Notice

Age Limit: our practice only accepts patients 18 years of age and older
Our providers DO NOT prescribe or manage Suboxone (buprenorphine and naloxone) or Clozoril (clozapine)
Our practice does not accept cases related to: workers compensation, auto accident, personal injury, court order psychiatric evaluations or pre-surgical psychiatric evaluations.

Click on the Welcome Letter image to read

⇦⇦

Step 1

Then click the button below to check the insurance plans we are in-network and if we are accepting new patients with your insurance plan.

Also, call your Primary Care Provider (PCP) or current mental health provider and have them fax us a new patient referral to 941-375-0119. Your insurance may not require it, but we are requesting this please.

NEW THERAPIST, Nancy Stetter-Coblentz, LCSW accepting new patients. Please note she is currently in-network with Traditional Medicare and Aetna Medicare PPO and HMO plans and Aetna commercial ins PPO and HMO plans (non-medicare). We are working to add her to more insurance panels. Please click on the button below for updated list.

Check Insurance Plans

Initial Visit Deposit

Step 2

NOTICE:

*Age Limit: our practice only accepts patients 18 years of age and older
*Our providers DO NOT prescribe or manage Suboxone (buprenorphine and naloxone) or Clozoril (clozapine)
*Our practice does not accept cases related to: workers compensation, auto accident, personal injury, court order psychiatric evaluations or pre-surgical psychiatric evaluations.

If any of the above conditions are valid to the patient, then unfortunately we will not be able to schedule and proceed.

-----------------------------------------------------------

Before scheduling your first visit with us, we require a $60 initial visit deposit. This is to secure your appointment date and time with our office. See our Welcome Letter document for details on this deposit.

After you pay your Initial Visit Deposit, then come back to this page to complete Steps 3 and 4 below.

Step 2: Pay $60 Initial Visit Deposit now

Online Form -Authorization to Use and Disclose of Information

Step 3

Medical Records Release of Information (ROI) Form

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 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.

Step 3: Complete Now

Online Form - New Patient Registration

Step 4

Last step to complete.

Please prepare yourself by taking photos or scanning your photo ID and all insurance cards (front & back sides). You will be able to upload your ID and insurance cards directly into this online form.

Step 4: Complete Now

or Paper Form

If you are not able to to complete the Online version then download New Patient Registration Form and write in your responses. Return your completed form to our office by using the Upload Document feature on our website, mail back to us or drop off at our office.

Download Paper Form

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

New Patient Registration form is required for all new patients and patients that have not been seen 3 or more years ago. Complete preferred method of the Online form -OR- you can download the 'Paper Form' and write in your responses.

Benefits of the Online Form: you have the ability to upload documents such as photo id, insurance card (front and back side), prescription drug benefit card, most recent lab results, medication list and other documents. We also receive your information immediately after you submit your form.

Welcome Letter, Initial Visit Deposit requirement, Map/Directions to our facility and Checklist of what to do
Welcome to Cornerstone letter V01.21.pdf
Adobe Acrobat document [137.9 KB]

Paper Form - New Patient Registration
Patient Registrationv0121.pdf
Adobe Acrobat document [276.2 KB]

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

Authorization to Release of Information (ROI)
Authorization to Release Information v01[...]
Adobe Acrobat document [68.8 KB]

The following 3 forms are for you to review and keep for reference:

Patient Rights and Responsibilities
Notice of Privacy Practices
Office Policies

HIPAA - Notice of Privacy
NoticeofPrivacy-v0318.pdf
Adobe Acrobat document [2.7 MB]

Patient Rights and Responsibilities
Patient Rights and Responsibilities Form[...]
Adobe Acrobat document [17.6 KB]

Cornerstone Psychiatric Office Policies
Office Policies-v0618.pdf
Adobe Acrobat document [93.6 KB]

Additional Documents:

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

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]

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.pdf
Adobe Acrobat document [139.8 KB]

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 v0121.pd[...]
Adobe Acrobat document [184.4 KB]

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

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 [98.5 KB]

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.

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]

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]

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]

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 do not call the office for this rx refill request and 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

Cornerstone Psychiatric Services, Inc.

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

Phone: (941) 488-8884

Fax: (941) 488-5554

(941) 375-0119

New Patient Registration Steps

You must complete ALL 4 steps before we will call you to schedule the appointment.

Notice

Initial Visit Deposit

Online Form -Authorization to Use and Disclose of Information

Online Form - New Patient Registration

or Paper Form

Upload Documents

Additional Patient Forms

Release of Information (ROI)

Online Form - Medical Records Release of Information

or Paper Form

Only for use by current active patients of Cornerstone Psychiatric

Cornerstone Psychiatric Services, Inc.

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

Phone: (941) 488-8884

Fax: (941) 488-5554

(941) 375-0119

New Patient Registration Steps

You must complete ALL 4 steps before we will call you to schedule the appointment.

Notice

Initial Visit Deposit

Online Form -Authorization to Use and Disclose of Information

Online Form - New Patient Registration

or Paper Form

Upload Documents

Additional Patient Forms

Release of Information (ROI)

Online Form - Medical Records Release of Information

or Paper Form

Only for use by current active patients of Cornerstone Psychiatric

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