Existing Patients

When necessary, our providers will request that you complete one (or more) of the following forms via the patient portal. Only if you are unable to complete them via the portal, please download, complete, and send the completed forms provided below via fax to 847-929-9138.

ADI Patient Guide, Acknowledgement of Practice Policies, and Consent for Treatment

All existing patients will be required to accept the OnPatient invitation and are asked to review these policies at every visit.

In Case of Emergency

As outlined in this guide, if you are experiencing an emergency and/or life-threatening situation, please call 911. If you are hospitalized or require urgent assistance / care during non-business hours, Dr. Sharma can be reached via her answering service at 800-330-1275. All non-urgent calls will be billed a minimum of $25.

Credit Card on File (Required for All Patients New & Old; HSA’s not Accepted)

To be filled out by all patients new & old. PLEASE DOWNLOAD, complete, save as PDF, and upload/send as via portal messages with the subject line “Credit Card on File Agreement.”

If you are having issues sending this via your Portal, please send it to support@adi.health with the subject line “Credit Card on File Agreement.”

Release of Information (“ROI”), aka Authorization for Use or Disclosure of Information for Patient Care

Under the Health Insurance Portability and Accountability Act (HIPAA), this form must be completed to disclose specified health information and release information for patient care purposes to the authorized user.

Medication Consent (Required For All New Medications/Prescriptions)

This form is to be filled out upon the request of the doctor. Patients must submit the completed form (with name of patient, parent (if applicable), pharmacy information, medication name and dosage, and signature) back via the portal as a message (or if necessary, to support@adi.health) in a timely fashion. Delays in returning a signed copy of the form will result in a delay of your prescription.

Parent Questionnaire (Required For New Patients Under the Age of 18)

To be filled out by all parents of patients under the age of 18, or as requested for the purpose of evaluation.

New Patients

Step 1: Complete the New Patient Documents and Appointment Request Form

Step 2: Schedule Your New Patient Appointment(s)

Once we review and approve your information, you will receive a notification from Insync. When this happens, please message the onboarding team via the patient portal requesting your initial evaluation appointment(s) AND call 847-577-7705 to request an onboarding call.

All patients seeking a diagnostic initial evaluation with a psychiatrist are required to complete two appointments (60m for the initial evaluation PLUS 30-40m 1-2 weeks later to complete the initial evaluation and create the treatment plan). Once these appointments are scheduled, you will receive links for your telemedicine visits (if applicable) via email and your patient portal. At this time, you will also be required to complete additional paperwork AND submit required documentation via the patient portal.

**If this is not completed within 48 hours of scheduling your appointment(s), your appointment(s) may be cancelled and released to another patient on our waitlist.

Step 3: Complete Additional Requested Paperwork/Forms via your Patient portal

Once you are scheduled for your initial evaluation, please log in to your patient portal to complete your profile, upload images of your insurance card and drivers license (front and back of card), submit any additional medical records necessary for diagnosis and evaluation, upload any/all legal agreements, submit the required credit card agreement with a card on file (HSA’s are not accepted), and review & sign off all policies and consent forms.

**If we do not receive these documents within 48 hours of your appointment being scheduled, your appointment may be cancelled and released to another patient on our waitlist.

Which forms will you need to submit via your patient portal? (Examples of forms and documentation included below)

  1. An Authorization for Use or Disclosure of Information for Patient Care (ROI) should be completed for any/all parties that you would like to authorize our team to connect with regarding your care. This could include a family member, therapist, or provider from whom we should connect with regarding your medical records (REQUIRED FOR ALL PATIENTS WHO CURRENTLY HAVE A PSYCHIATRIST OR THERAPIST, AND FOR ALL PATIENTS OVER THE AGE OF 18 WHO WOULD LIKE THEIR PARENTS/ANOTHER PARTY TO BE INVOLVED IN THEIR CARE)

  2. Credit Card on File Agreement with a Credit Card on File (HSA’s are not accepted/allowed)

  3. Parent Questionnaire (REQUIRED ONLY FOR PATIENTS UNDER THE AGE OF 19)

  4. Insurance Card (front & back)

  5. Drivers License (front & back - for the patient OR responsible party)Any additional information you’d like to share with the provider

  6. Any additional documentation/medical records that may assist with diagnosis and/or evaluation. Medical records can also be faxed to 847-929-9138.

  7. Legal guardianship documents (if applicable)

  8. Legal parenting agreements/court orders required for children of divorced parents (if applicable)

**If we do not receive these documents within 48 hours of your appointment being scheduled, your appointment may be cancelled and released to another patient on our waitlist.