Patient Forms

All patients are required to complete our patient registration forms prior to being seen. To save you time, registration packets are available below for downloading at home.

What do these forms entail?

First, we will need information regarding basic demographics and billing details (see “Demographics Form” below). Ensure you place your signature under “Medicare Lifetime Signature on File” and/or “Private Insurance Authorization for Assignment of Benefit/Information Release,” depending on the type(s) of insurance(s) you have.

Second, we need your permission to evaluate and treat you (see "Consent Form," below). A psychologist-client (patient) relationship cannot be established without your consent. Please read the “Psychologist-Client Service Agreement” carefully and sign.

Third, we need your permission to release your private health information, such as sending your report to another physician, your attorney, or discussing your case with a family member (see “Authorization For Release of Information” below). We will also require permission to obtain your medical and/or psychological records from other physicians or hospitals. You might need to print and sign more than one health information release form, one for each individual from whom you want us to share and/or obtain information. If you are asking us to send AND obtain information from the same source, please fill out two forms. Permission to release prior medical records is essential for a thorough and accurate assessment.

Fourth, Medicare patients will need to fill out a “Medicare Form (Medicare Patients Only);” patients with Commercial (non-government) insurance (primary and/or secondary) will need to complete an “Assignment of Benefits” form. These forms will enable Mind and Brain Care to receive payment for their services directly from the insurance company and will prevent erroneous billing to you. If you have both Medicare and a secondary private insurance, please fill out both forms.

Fifth, you'll receive a federally required "Good Faith Estimate." Since 2022, The No Surprises Act includes Good Faith Estimates and Patient-Provider Dispute Resolution Requirements to protect patients from unexpected medical bills. Good Faith Estimates require providers to give patients a clear cost estimate for non-emergency services before treatment. If actual charges exceed the estimate, the Dispute Resolution process allows patients to challenge and resolve billing discrepancies, ensuring fair and transparent healthcare costs. You will be informed of the maximum (worst case scenario) cost that could apply if insurance does not pay and you do not qualify for a clinical hardship discount. Each case varies in cost, and we will inform you prior to setting an appointment.

Finally, you'll need a Medical Necessity Form. Neuropsychological evaluations are considered medically necessary when they provide critical information about the diagnosis, prognosis, and treatment of disorders affecting the central nervous system (CNS). These evaluations are essential when specific cognitive impairments are suspected or identified and cannot be adequately addressed through standard medical or mental health care evaluations. To be covered by insurance, including CMS guidelines, the evaluation must meet specific medical necessity criteria. However, neuropsychological testing is typically not deemed medically necessary and is not covered when conducted primarily for educational purposes (e.g., learning disabilities, ADHD), vocational purposes (e.g., Fitness For Duty Evaluations), legal purposes (e.g., personal injury cases), or when it simply repeats previous testing without a significant change in functioning. Non-medically necessary evaluations are charged at the standard rate and do not qualify for fee reductions based on medical hardship.

If you experience difficulty filling out these forms, we can assist you prior to your appointment, but we ask that you arrive at least 30 minutes early to do so.

If you are unable to download or print these forms, we can mail them to you.