Patient Forms

All patients are required to fill our registration forms prior to being seen. In order to save you time, registration packets are below for downloading at home. 

What do these forms entail?

  1. First, we will need information regarding basic demographics and billing information (see “Demographics Form” below). Make sure you place your signature under “Medicare Lifetime Signature on File” and/or “Private Insurance Authorization for Assignment of Benefit/Information Release,” depending on type(s) of insurance(s) you carry.
  2. 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.
  3. Third, we need your permission to release your private health information (e.g., send you report to another physician, your attorney, or to discuss your case with a family member), see “Authorization For Release of Information” below. We will also need permission to obtain your medical and/or psychological records from other physicians or hospitals. You might need to print and sign more than one release of information if you are asking us to send AND obtain information. Prior medical records are essential for a thorough and accurate assessment.
  4. Finally, 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 fill out an “Assignment of Benefits” form. These forms will enable Mind and Brain Care to get paid for their services directly from the insurance company and will prevent us from erroneously billing you. If you have both Medicare and a secondary, private insurance, fill both forms out.

If you experience difficulty filling out these forms, we can help you fill them out prior to your appointment, but we ask that you arrive at least 15 minutes early in order to do so. 

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