Forms
Please print, fill out, and sign each form below and bring them to your first appointment.
If you are age 19 or older, bring “Demographics for Independent Adults” and if you are 18 or younger, bring “Demographics for Minors and Those with Guardians”
If you are age 19 or older, bring “Demographics for Independent Adults” and if you are 18 or younger, bring “Demographics for Minors and Those with Guardians”
Declaration of Practices and Procedures
Notice of Privacy Practices
Summary of the HIPAA Privacy Rule
Demographics for Independent Adults
Demographics for Minors and Those with Guardians
Presenting Problems and Concerns
Insurance Verification_Payment for Services Contract
Credit Card Authorization Form
Referral Source Questionnaire
Notice of Privacy Practices
Summary of the HIPAA Privacy Rule
Demographics for Independent Adults
Demographics for Minors and Those with Guardians
Presenting Problems and Concerns
Insurance Verification_Payment for Services Contract
Credit Card Authorization Form
Referral Source Questionnaire