Forms

Authorization Form for Release of Clinical Record

This form when completed and signed, authorizes me to release protected information from your (or your child’s) clinical record to the person or institution you designate.

Consent to Use and Disclose Health Information

Good Faith Estimate

Good Faith Estimate Acknowledgement

Informed Consent for Telehealth

Notice of Privacy Policies (HIPPA Compliance)

This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Client Services Agreement

This document (the Agreement) will provide you with information about my practice, office policies, and procedures. Signing this document will represent an agreement between us.

Patient Information Form

Permission to Use CC Form