New Patient Registration: These forms will provide us with the necessary identifying information and authorization to file with your individual insurance carrier. By signing the Patient Service Agreement you agree that you have been provided with access to the Patient Services Agreement as well as the HIPAA Notification and that you agree to its terms.
Patient History Form: In order to provide you with timely care we request that you bring this completed form with you to the first meeting with your provider.
Stimulant Refill Request: Print this form and either fax it or bring it to the office so that your medication provider can assist you in a timely manner.
Consent to Use Electronic Communication: Complete this form to acknowledge and authorize means of electronic communication including email, text messages, and/or videoconferencing.
DSM V Symptom Checklist: A brief 23 question checklist of common symptoms and pertinent issues.
CHPA Policies and Procedures: A description of CHPA's current policies.
Insurance Pre-Authorization Form: Most insurance carriers require pre-authorization for treatment to be covered. This usually entails calling customer service number on your insurance card and requesting authorization for outpatient mental health treatment. The attached form can assist you in documenting the information provided by your insurance carrier to ensure proper coverage.
Release of Information Form: This is a standard Release of Information Form (ROI) to facilitate the exchange of information between your CHPA provider and other pertinent provider(s) or person(s).
Telehealth Consent Form: This consent serves the purpose of facilitating communications between you and your provider via either telephone or videoconferencing.