This page contains downloadable versions of common forms used in my practice.
For new patients:
Informed consent form – discusses confidentiality, privacy, and informed consent for treatment. Also used to provide your emergency contact information, contact preferences, and insurance information. Please download, print, and fill out this form, and bring it to your first appointment with me.
Notice of Privacy Practices (HIPAA) – discusses my privacy practices and your rights under the law. Kindly download and read this before your first appointment with me.
For new and existing patients:
Release of information form – gives me permission to share information about your treatment with other healthcare providers, family members or other parties designated by you.
Arizona clients – Protocol for medical records – my protocol for access to your medical records, as required by Arizona Statute 32-3211.
You are also welcome to fax signed forms to me 24 hours a day at 607-235-5003.