TO OUR NEW PATIENTS

Here are THREE forms we’d like you to print from you computer and complete prior to your first appointment. This will save you considerable time, as you will not have to take the time to read and to sign these forms when you arrive. These forms (or some variation) are commonly used in mental health practices. All forms require your signature.

(1) Notification of Mental Health Policies & Practices Document
(2) Limited Release Form
(3) Fee Agreement Form

The Notification of Mental Health Policies Document explains the uses and disclosures of your protected health information established by the Health Insurance Portability and Accountability Act that goes into effect on April 14, 2003.

The Limited Release Form should be completed by you only if someone other than you might be calling INTROSPECT on your behalf for making appointments, verifying appointments, or for billing inquiries. Without this authorization we cannot provide any information whatsoever to anyone who calls with these or any other requests.

The Fee Agreement Form describes your financial responsibilities. Please make special note of the following, “Fees for missed appointments or appointments cancelled less than 24 hours in advance are never waived except for true medical emergencies or state and locally sanctioned emergencies.” There are no exceptions to this policy!

Should you have any questions regarding any of these forms discuss them with your INTROSPECT provider prior to signing them. Otherwise, sign the forms and hand them to the receptionist upon your arrival.

Thank you!

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