WELCOME TO AMEN CLINICS

TO OUR FRIENDS, FAMILY AND PATIENTS

Welcome to Amen Clinics.

On behalf of our physicians, staff and affiliates, thank you for choosing us to be your mental health
treatment provider. We’re dedicated to providing you and your family the highest level of care.

We developed this packet to help prepare you for your clinic visit, to inform you of some of the main
services we offer, and to help make your treatment experience with us as smooth as possible.

We’re excited for the opportunity to help you. With the world’s largest database of functional brain
scans from tens of thousands of patients from all 50 states and 155 countries, our physicians can
more accurately diagnose and treat patients – so that you can change your brain, and change your life.

We look forward to partnering with you on your journey to better brain health.

Daniel G. Amen, MD Dr. Robert Johnson, DO

Founder, Amen Clinics Medical Director, Amen Clinics

WELCOME PACKET-EVALUATION | AMENCLINICS.COM 2

WELCOME PACKET-EVALUATION

This packet contains important details and policies regarding your upcoming visit to Amen Clinics. Please
review this information before your first appointment.

Please Note: You may or may not be scheduled for all of the appointment types discussed in this packet.

TABLE OF CONTENTS

TO OUR FRIENDS, FAMILY AND PATIENTS 2

WELCOME PACKET-EVALUATION 3
BEFORE YOUR APPOINTMENT 4
FULL EVALUATION 5
Clinical History 5
Total Brain Online Assessment 5
SPECT Scans 6
During Your Appointment 6
Medication and SPECT 6
Final Evaluation 7
Amen Clinics Method Coaching 8
Follow-Up Appointments 8
CANCELLATION/RESCHEDULE POLICIES 9
INSURANCE PROCEDURE CODES 10
FREQUENTLY ASKED QUESTIONS 11

WELCOME PACKET-EVALUATION | AMENCLINICS.COM 3

BEFORE YOUR APPOINTMENT

THIS CHECKLIST WILL HELP YOU PREPARE FOR YOUR VISIT:

† Complete your online enrollment through the patient portal. Login information will be emailed to you.
Please complete enrollment no later than 2 business days before your first appointment.

Tip: To avoid losing your data as you fill out your information, regularly save your progress.

† Complete the Total Brain Online Assessment at home, if possible. If not, we have a time and space for
you to complete it at the clinic.

† Confirm appointment times and arrive 15 minutes early for your first appointment.

† Please complete your consent forms online or bring your completed consent forms to your first
appointment.

† Read the medication guidelines ON PAGE 6 and contact your prescribing physician if you wish to
discontinue or decrease your current medication(s), if any. Stimulant medications should be
discontinued 4 days before each scan.

† Avoid caffeine, aspirin, cold medications, alcohol and illicit drugs the day of your scans.

† No fasting is required (unless you’ve scheduled a child for a sedation scan in the Costa Mesa, Chicago, or
New York clinics). No chewing gum 30 minutes before scan. DRINK PLENTY OF WATER to stay hydrated.

† Bring a list of your current doctors and treatment teams for your medical release form.

† For your history interview, bring any previous blood work and lab results done in the last 2 years,
along with medical records to the session. (This is optional).

† Be prepared to pay your remaining balance when you arrive at the clinic.

† Review and understand the cancellation and deposit policy.

† Book travel arrangements. If you’re coming from out of town, we will provide a list of local
accommodations.

WELCOME PACKET-EVALUATION | AMENCLINICS.COM 4

FULL EVALUATION
This comprehensive evaluation will allow us to create a personalized and targeted treatment plan for you. It will
involve several highly-trained professionals, including your physician who you will meet with on the last day.

CLINICAL HISTORY

During this appointment, one of our trained Outcome Managers will discuss your symptoms, medical and mental
health history. Everything discussed during your intake appointment may be included in your final report (unless
otherwise specified by you). Your best answers will allow your doctor to develop the best treatment plan for you.

TOTAL BRAIN ONLINE ASSESSMENT

| Total Brain Online Assessment is an objective, web-based emotional and cognitive neuro-diagnostic testing
service. It’s an important part of our evaluation process.

| It will ask questions to examine how you’ve been feeling and functioning over the past week or so. It will also give
you game-like tasks to complete. There is no pass or fail.

| Requirements to take the test:

y The patient must be able to read English.
y The test requires a keyboard with a mouse (or a touch pad).
y It takes around 40 minutes to complete.
y A high-speed Internet connection is recommended but not required.
y For the assessment to run properly, close all other computer applications during the test.

| Prepare the room: Make the room as quiet as possible and decrease distractions, so you can better concentrate.

| Parent’s role as a supervisor (for patient’s ages 6-17)

y Let your child know that you are available to help them read and understand the instructions at any time.
Once the instructions are understood, and the assessment has begun by clicking the OK button, you should
allow your child to complete the task questions on their own, even if they struggle with it.
y It is important that your child complete the test without pressure to perform. Do not sit behind your child and
watch them take the test. Allow them to be independent, but be close enough to clarify the instructions for
them, if needed.

| If you’re unable to complete the test, you can use scheduled time in the clinic to complete it.

WELCOME PACKET-EVALUATION | AMENCLINICS.COM 5

FULL EVALUATION

SPECT SCANS

At Amen Clinics, we use brain single-photon emission computed tomography (SPECT) imaging as a tool to diagnose
and treat patients. SPECT allows us to look inside the brain and see in 3D three important areas of the brain:

1 Areas that work well

2 Areas that work too hard

3 Areas that do not work hard enough

This information is analyzed and used throughout your treatment.

Your scans and clinical history help us understand the underlying brain patterns associated with your issues
and help us pinpoint the right treatments. For detailed information on the benefits of SPECT imaging, visit
www.amenclinics.com

DURING YOUR APPOINTMENT

To inject the medicine for the scan, a small IV will be started in a vein in your arm. Afterwards, you will lie down on a
table so the SPECT camera can take the image of your brain’s activity.

If you have an acute sensitivity to pain or a fear of needles, we offer EMLA® Cream (lidocaine, prilocaine) to numb
the administered area. To use this option, please let us know when you schedule and arrive at the clinic 30 minutes
before your scan.

Most people get two scans, one while doing a concentration task, and one at rest. If you are only having one scan, it is
typically done with a concentration task. During the concentration scan, you will take a 15-minute computerized test
that measures attention and focus. During the resting scan, you will be instructed to sit quietly.

The SPECT process takes typically 20 to 25 minutes for each scan and requires you to be COMPLETELY STILL. Once the
scan’s data has been collected and approved, your scan appointment is done for the day. The scan technologist will
guide you through the process and will answer any questions you may have.

MEDICATION AND SPECT

Some people are cautious about being scanned while on medications. In general, we recommend patients to
discontinue stimulants, such as Ritalin and Adderall, 4 days before the first scan and to stay off of them until the
second scan is completed. If you are concerned about going off your stimulants for the full four days, please know
that many patients get scanned on their medications, and their scans are still extremely valuable to their treatment.

IMPORTANT: Never discontinue any necessary medications or supplements, especially if they’re needed for daily
functioning. These include, but are not limited to, psychiatric medications and medications for blood pressure, blood
thinners, diabetes, thyroid, heart and lungs. If you decide to be scanned off all medications and supplements, YOU
MUST do so under the guidance of your healthcare provider. Always check with your doctor before reducing or
discontinuing any medication.

WELCOME PACKET-EVALUATION | AMENCLINICS.COM 6

FINAL EVALUATION

After testing, history and scans have been completed, you will meet with a physician for your final evaluation. Though
you will not meet with Dr. Amen, you can be confident in knowing that each of our physicians has been selected,
trained and approved by him. Dr. Amen regularly consults with our doctors and medical professionals.

During the appointment, the physician will review your test results, clinical history, and scans. For telehealth
appointments, please use a computer with a camera for your evaluation appointment (not a cell phone).

 

YES NO
 

Additional information may be requested from you, and any questions you may have will be addressed. Your
physician will develop an individualized treatment plan for you. The written report of your final evaluation will be
completed after your appointment.

Your treatment plan may or may not include recommendations for prescription medications. We cannot guarantee
you will receive a written prescription. Your physician will also discuss whether or not it’s possible to continue
treatment at our clinic. If you’re from out-of-state or another country, it’s recommended that you find a physician in
your area who is willing to collaborate with us before your visit. We can then work with your local doctor in prescribing
agreed upon medications. State laws may prohibit us from writing prescriptions for patients who are out-of-state. If
you are unable to establish care with a local doctor, before coming to Amen Clinics, we can make a recommendation
for you from our current referral list, but can’t guarantee we have an affiliate in all areas.

Amen Clinics is often used by people around the world as an ongoing consultation service. Our recommendations
often include treatments other than prescription medications (e.g. natural supplements, dietary changes, nutrition
plans, exercise, and various forms of therapy) that can be implemented at home or with a local practitioner.

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AMEN CLINICS METHOD COACHING

Included in your evaluation are two 20 to 25-minute

appointments with your Outcome Manager. These can
be done by phone or in person.

The first appointment is scheduled approximately two

days after your evaluation. It is a follow-up appointment
to help you complete the next steps in your treatment
and answer any questions you may have.

The second appointment is also a follow-up. This

appointment is scheduled after you’ve had some time
to get started on your treatment plan. During this
appointment, your Outcome Manager may spend time
coaching, troubleshooting personal challenges and
helping you find additional resources.

FOLLOW-UP APPOINTMENTS

The first follow-up appointment with your physician

is typically scheduled 2 to 4 weeks after your Final
Evaluation. The second appointment is typically
scheduled 4-8 weeks after your Final Evaluation.

These appointments are used to discuss treatment

progress and address any questions or concerns.
Patients who live too far from our clinics or who do not
continue care with us can do their follow-up appointment
over the phone.

WELCOME PACKET-EVALUATION | AMENCLINICS.COM 8

CANCELLATION/RESCHEDULE POLICIES

PLEASE REVIEW AND UNDERSTAND OUR CANCELLATION AND RESCHEDULE POLICIES BELOW:

CANCELLATION POLICY:

Due to the complex nature of our evaluation process, a deposit is required to schedule your appointment(s). This
initial deposit must be paid at the time appointments are scheduled. Your deposit will be applied to the complete
payment of services.

To receive a refund of your initial deposit, you must cancel your first appointment no later than 3 business days
AFTER SCHEDULING your appointment.

RESCHEDULE POLICY:

If you would like to reschedule your appointment, you must notify the clinic no later than 3 business days BEFORE
YOUR FIRST SCHEDULED APPOINTMENT; otherwise, you will forfeit your deposit.

Changes or cancellations of consultations must be made 24 business hours before their scheduled time. For
example, the 24 business hours would require that an appointment for 9:00 AM on Monday be canceled no later
than 9:00 AM the prior Friday to avoid being charged.

PAYMENT INFORMATION:

ACI is a fee-for-service clinic. We require that you pay before (or at the time of) a scheduled appointment. Personal
checks, cashier’s checks, Visa, MasterCard, American Express, Discover, and Care Credit are accepted. We do not
accept cash.

INSURANCE/MEDICARE:

Amen Clinics is an out-of-network provider. We do not bill insurance and are not Medicare, Medicaid, or Medi-Cal
providers. At the end of the evaluation, patients are given a superbill containing applicable diagnosis and billing
codes, which can then be submitted to insurance companies for possible reimbursement. For Medicare, Medicaid,
or Medi-Cal patients, you will not be able to file claims with them, and you will not receive reimbursement. Our
doctors and therapists are not affiliated with any insurance plans or networks. As a result, insurance carriers will
regard fees and treatment incurred at the Amen Clinics as an out-of-network procedure. Please check with your
insurance provider for any mental health benefits.

WELCOME PACKET-EVALUATION | AMENCLINICS.COM 9

INSURANCE PROCEDURE CODES

Tax ID: 91-2055998

The following insurance procedure codes have been provided for reference. The fees associated with each procedure
are also listed. Fees are subject to change without notice.

CPT Code Description Fee

SPECT SCANS

78803 Tomographic (SPECT) Scan when completing one scan $1,440

78803 Tomographic (SPECT) Scan when completing two scans $1,310/scan

96146 Psych. Testing (computer-assisted), when completing $155

Concentration Scan

CLINICAL HISTORY

99205 Initial Comprehensive and Management Evaluation $345

90889 Preparation of Initial Report $100

DOCTOR’S EVALUATION

90792 Psychiatric Diagnostic Evaluation $425

90885 Psychiatric Evaluation of Records, Reports, and Tests $75

90887 Interpretation or Explanation of Results $175

90889 Preparation of Final Report $75

96130 Psych. Testing $100

FOLLOW-UP

99242 Office Consultation (20 to 25 minutes) $212.50

99214/90833 Med Management/Therapy (20 to 25 minutes) $212.50

*Prices are subject to change.

WELCOME PACKET-EVALUATION | AMENCLINICS.COM 10

FREQUENTLY ASKED QUESTIONS
WHAT IS THE IV INJECTION AND ARE THERE ANY
SIDE EFFECTS?
A SPECT scan requires the injection of a very small amount
of radiopharmaceutical (Ceretec) intravenously. The
medicine we inject is not an iodine based dye. Side effects
are rare, but may include headache, fever, and rash.
HOW MANY DAYS DO I NEED TO BE AT THE CLINIC?
You should allow 2 to 3 days for the full evaluation.
These days do not need to be consecutive unless you
live outside the area.
WHAT IS THE SUCCESS RATE?
At Amen Clinics, on average we treat people who
have failed more than 3 providers and 5 medications.
In a formal outcome study on over 5,000 patients,
after 6 months 76% of patients report significant
improvements. That number climbs to 84% if they
continued their treatment at Amen Clinics. Many factors
can affect the outcome, such as willingness to follow the
treatment plan, age, and severity of symptoms.
WILL I MEET DR. AMEN PERSONALLY?
Currently, Dr. Amen is unable to take on new patients,
and his waiting list is closed. You can feel confident
that Dr. Amen has personally handpicked and has
trained all of our physicians at Amen Clinics.
DO YOU OFFER ANY DISCOUNTS, PAYMENT PLANS
OR FINANCIAL ASSISTANCE?
Yes, we do. From time to time, we offer special
promotions and discounts with limited time offers.
To be the first to receive these special offers and
discounts, subscribe to Dr. Amen’s Newsletter at
www.amenclinics.com/newsletter
WELCOME PACKET-EVALUATION |
HERE ARE A FEW DISCOUNTS AND A FINANCING
OPTION.
1. Patient Referral Discount: We offer a 10%
discount for friends and family members of
previous patients that schedule an appointment
with our clinics. The original patient must have
had a completed full evaluation with SPECT.
2. Family First Discount Plan: We have a family
plan that allows you to save more on your
evaluation when booking 2 or more family
members at the same time. To learn more, go
to www.amenclinics.com/family-discount-plan
3. Care Credit: We offer a financing option through
a third-party company called Care Credit. You
can apply for an account at www.carecredit.com
or call 866-893-7864.
DO YOU OFFER PHONE CONSULTATIONS BEFORE
SCHEDULING AN APPOINTMENT?
Yes. If you would like to schedule a consultation with a
physician, you can do so by calling our Care Center at
888-288-9834. The charge for a 20-30 minute session
is $212.50 and a 45-60 minute session is $425.
CAN MY AMEN CLINICS PHYSICIAN BECOME MY
REGULAR DOCTOR?
This is something you can discuss this with your
Amen Clinics physician, and he or she will see if it is
appropriate. If you already have another physician, we
ask that you discuss this option with your doctor first.
WHAT IF I HAVE QUESTIONS AFTER MY
EVALUATION?
You will have four appointments with your care
team after your evaluation. You can ask questions
then, and also reach out to your doctor in between
appointments with quick questions. Additionally, we
are happy to provide a consultation to you or your
doctor in the future should additional questions arise.
Fees may apply.
AMENCLINICS.COM 11
CORPORATE OFFICE
3150 Bristol Street, Suite 400
Costa Mesa, CA 92626

CLINIC LOCATIONS

ATLANTA
5901 Peachtree-Dunwoody Road, Suite C65
Atlanta, GA 30328
CHICAGO
2333 Waukegan, Suite 150
Bannockburn, IL 60015
DALLAS
7301 State Highway 161, Suite 170
Irving, TX 75039
LOS ANGELES
5363 Balboa Blvd., Suite 100
Encino, CA 91316
NEW YORK
16 E 40th Street, 9th Floor
New York, NY 10016
ORANGE COUNTY, CA
3150 Bristol Street, Suite 400
Costa Mesa, CA 92626
SAN FRANCISCO
350 N. Wiget Lane, Suite 105
Walnut Creek, CA 94598
SEATTLE
616 120th Ave NE, Suite C100
Bellevue, WA 98005
SOUTH FLORIDA
200 South Park Road, Suite 140
Hollywood, FL 33021
WASHINGTON, D.C. www.amenclinics.com
10701 Parkridge Blvd., Suite 110 1-888-288-9834
Reston, VA 20191