Helpful Forms

If you’re a new client, please complete the following forms and bring them to your first therapy session.

NEW PATIENT FORMS

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MEDICARE FORMS

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NOTICE OF PRIVACY POLICY

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If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

Authorization to Disclose Information Form

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Medicare allows reimbursement to the patient directly for money spent to pay for out-of-network medical providers. Once I give you a receipt that will have the appropriate medical and treatment codes, you can attach it to this medicare form to request reimbursement from Medicare and your secondary insurance. I do not know the exact amounts you will be reimbursed but clients tell me it is significant.

Medicare Out Of Network Form

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