Please print, fill out and bring forms 1, 2 and 4 to your session:
1-Office Policies and Procedures . Print signature page on its own separate sheet
(Should you desire to access full US Government HIPAA booklet, go to 'Privacy & Policy' page and click on link provided )
2-Your Rights Under HIPAA. This is yours to read and keep.
/userfiles/4625985/file/Your Rights Under HIPAA _ HHS_gov(1).pdf
3-Client Intake form
4- * Health Insurance Claim form ( * Only if I am a
provider for your insurance plan and will be filing the claim for you. Not
needed if you are filing your own claim or not using insurance)
userfiles/4625985/file/Health Insurance Claim Form 2014(3).pdf
5 - ** Release of Information ( ** only if you are requesting and authorizing me to contact a person of your choice, such as a psychiatrist or primary care physician.
/userfiles/4625985/file/Release of Information Authorization.pdf
6 . Telehealth Informed Consent Form (only for telehealth purposes)
/userfiles/4625985/file/Telehealth Informed Consent Form.pdf
Note: To download Adobe Acrobat Reader for free, click here .