Forms


To Fill Out Before Your First Visit:

Face Sheet & Insurance Claim Information

Notice of Privacy Practices

Notice of Practice Policies

Acknowledge Practice Policies

Directions on Completing Forms


You may want to review and print the "Therapy Menu" to focus on what you want to accomplish.


Authorization to Release Protected Health Information (PHI) (Allows me to share information with your other provider)

TeleMedicine Consent (Only for therapy over the phone or internet)


Other HIPAA Forms, optional:

Request to Amend Protected Health Information (PHI)

CMS 1500 Standard Claim Form

Complaint Form (to CMS about privacy violations)


Return to Intake Checklist


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This work by Lew Mills is licensed under a Creative Commons Attribution 4.0 International License