Printable Patient Forms
To avoid extended wait times, please fill out the following four forms prior to your appointment.
If you would like us to obtain medical records or disclose information, please fill out the following form.
Billing And Insurance
Medical Records Release & Confidentiality
Your medical information is kept in strict confidence. Before your records are released, you will need to sign a medical release authorization found above. Your medical information can also be viewed, downloaded or transmitted through your patient portal account.
Our policy is to only refill medications Monday-Friday during regular office hours. Refill requests should be placed at the pharmacy. If you are out of refills, the pharmacy will contact our office. If you call the office for a medication refill, please have the name of the medication and your pharmacy number ready. Refill requests can also be sent through your patient portal.
Good Faith Estimate Notice
You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.
You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.
Effective date of notice: 1/1/2022