Thanks for putting us on the right track!
ColonelUnited States Air Force and spouse

Patient Forms

The following forms are important and will help us establish a clear and
 effective relationship. To print the forms will require Adobe 
Acrobat Reader. If you do not have this program on your computer, you can 
download it for free by clicking here.

PLEASE PRINT, COMPLETE, SIGN, AND BRING TO YOUR FIRST
 SESSION:

Office Policies and Procedures This form explains my office policies, includes a description of my services, and contains 
important information about your confidentiality. If you have questions 
after reading this form, please bring them up when we meet.

HIPAA Notice of Protected Health Information 
I am required by law to provide you with a copy of the HIPAA Notice of Privacy Practices. This notice is meant to help you understand your rights and protections related to the use and disclosure of your protected health care information. Please keep the Notice for your records. Sign and bring the Signature page to our first appointment.

Biographical Information 
Prior to our first session, please complete the patient information form. This form will help you to share important details about yourself. The information you provide will help me to get to know you more quickly and provide treatment for your specific needs.

Authorization to Release Information 
Complete and sign this form to authorize care coordination. This form gives your permission for me to coordinate your care with other parties or health care providers (for example, your primary care physician or other care providers).

IF YOU HAVE BEEN REFERRED FOR NEUROPSYCHOLOGICAL EVALUATION, PLEASE SIGN AND BRING TO YOUR FIRST SESSION:

Consent for Neuropsychological Services This form explains the neuropsychological evaluation process, including a description of the neuropsychological evaluation. It also contains important information about your confidentiality.

IF I AM NOT A ‘WITHIN NETWORK PROVIDER’ FOR YOUR HEALTH INSURANCE COMPANY, YOU CAN ASK FOR A SINGLE CASE AGREEMENT.

Single Case Agreement for Neuropsychological Services This letter provides you with important information needed to request a “Single Case Agreement” for neuropsychological services with your private health insurance company. With this agreement between your health insurance company and me, I will be treated as a “within network provider” for your portion of the deductible and co-pays.

Payment for Services

Click “Pay Now” below and you’ll be taken to PayPal’s secure site to complete the payment. Fill in the amount you wish to pay on that form, under “Item Price”.

Thanks!