Please complete to following forms for your appointment:
/userfiles/2079575/file/Child Information Form(1).doc
/userfiles/2079575/file/BibliographicalInformationForm.pdf
/userfiles/2079575/file/covid19.pdf
If you would like me to coordinate care with another provider, psychiatrist
or medical doctor please complete the following form
userfiles/2079575/file/HIPPA Authorization Form.pdf
If you would like to preview a copy of our Privacy Practices, please view it
here:
userfiles/2079575/file/privacypractices.pdf
Note: To download Adobe Acrobat Reader for free,
click here .
Good Faith Estimate
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 health care 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
