NEW PATIENT FORMS NOW AVAILABLE ONLINE
Electronic & Downloadable Patient Forms
We are excited to announce that our clinic is now offering the option for new patients to complete their forms electronically or download and print them at home. This will make the registration process more convenient and efficient for our patients. We encourage all new patients to complete their forms prior to their first appointment to ensure a smooth check-in process. If you have any questions or concerns, please don't hesitate to contact us.
Patient Forms
- Patient Registration (Español): Electronic | Download
- Consent to Treat: Electronic | Download
- Consent to Treat (Español): Electronic | Download
- Consent for Telehealth Consultation: Electronic | Download
- Authorization to Release of Medical Records: Electronic | Download
- Health History Questionnaire: Electronic | Download
- Privacy Policy: View here
- Notice of Privacy Practices: Electronic | Download
- Notice of Privacy Agreement to Treat: Electronic | Download
- Consent for Treatment with Buprenorphine/Naloxone: Electronic | Download
- Agreement for Treatment with Buprenorphine/Naloxone: Electronic | Download
- Release of Medical Records: Electronic | Download
- Acknowledgement of Notice Practice (Español): Electronic | Download
- Acknowledgement of Practice Policies and Consent: Electronic | Download
- Patient Practice Policies: Download
- Telemedicine Policies and Procedures: Download
Patient Appointment Responsibilities
To ensure quality care and efficient scheduling, we kindly ask that all patients adhere to the following appointment responsibilities:
1. Arrive on Time
Please arrive at least 10–15 minutes prior to your scheduled appointment to allow time for check-in and any necessary paperwork.
2. Cancel or Reschedule in Advance
If you are unable to attend your appointment, please notify the office at least 24–48 hours in advance. This allows us to offer the appointment slot to another patient in need of care.
3. No-Show Policy
Failure to attend a scheduled appointment without prior notice may be considered a “no-show.” Repeated no-shows may result in limited appointment availability or discharge from care.
4. Late Arrivals
If you arrive late, we will do our best to accommodate you. However, depending on the schedule, you may be asked to reschedule so we can remain on time for other patients.
5. Keep Contact Information Updated
Ensure that your phone number, email, and mailing address are current so that we can reach you regarding your appointments or any changes.
6. Be Prepared for Your Visit
Bring your ID, insurance card, list of medications, and any relevant medical records or forms. If you're being seen for a specific issue, make note of your symptoms and any questions you’d like to ask the provider.
7. Follow-Up Scheduling
If your provider recommends a follow-up visit, please schedule it before leaving the office or contact us promptly to do so.
Your cooperation helps us provide timely and effective care to all patients. We appreciate your understanding and commitment to your health.
Financial Fees and Obligations Policy
Our practice is committed to delivering quality care while ensuring transparency regarding financial responsibilities. Please review the following policies related to fees, payments, and obligations.
Medicaid Patients
• Medicaid recipients are exempt from any financial obligations for covered services.
• Missed or late-cancellation appointments will not be billed to Medicaid clients.
• No co-payments, deductibles, or co-insurance are required.
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Please ensure that your Medicaid coverage is current and active at the time of your appointment.
Private Insurance and Self-Pay Clients
Payment Requirements
Payment is required for all appointments, including initial evaluations and follow-up visits.
• This applies to all services, including but not limited to:
o Psychotherapy
o Medication Management
o Weight Loss
o ADHD Testing
Estimated Costs
- If you are using private/commercial insurance, your financial responsibility may include:
- Deductibles: The out-of-pocket amount you must pay before your insurance begins to cover services.
- Co-Payments: Fixed fees required at the time of service.
- Co-Insurance: A percentage of the total service cost you may owe after meeting your deductible.
We provide good faith estimates upon request. Final charges are based on the actual services provided and your insurance’s processing of claims.
Outstanding Balances
- You are responsible for any remaining balance not covered by your insurance.
- Failure to pay fees and/or co-payments may result in the cancellation of future appointments until balances are resolved.
Updating Information
Payment Requirements
• Mailing address
• Phone number
• Insurance coverage and policy details
Failure to update this information may result in delays in care, claim denials, or billing issues.
If you have any questions or need assistance understanding your financial obligations, please contact our office.
Thank you for choosing our practice. We value your trust and are here to support your care journey.
Completing Your Health Information Is Easier Than Ever with Our Electronic and Downloadable Formats.
