Forms
Forms
Welcome! Please fill out the release of information form and the initial intake packet before your first visit. You can submit them on the HIPPA-compliant online form.
Intake Packet
Patient packet, disclosures, payment options, cancellation policy and insurance coverage
Medication Contract
A variety of agreements regarding medications
Prior Authorization Status Request
Release of Information Form & Letters and Forms Requests
Authorized disclosure of medical treatment &Transfer medical records
Refill/Question Request
Medication refill or additional requests/information. Note, Online requests are processed before phone requests.
Patient Information
Due to increased demand for services, there is a $50 deposit required to schedule an initial consultation with our providers. This payment may be made over the phone using Visa, MasterCard, or Discover Card. In the event this appointment is not kept, the deposit is non-refundable. If the appointment is kept the deposit will be used as a credit applied to fees for services.
