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Forms

To speed and assist you with registration, our basic registration packet is available below.   Please note that all forms marked with an asterisk (*) require a signature by the person(s) with legal authority to consent to the patient's treatment.  Call us at (608) 242-7160 if you have questions.  Forms should not be signed before all questions are answered and/or any concerns are addressed. 

 

1. HIPAA Privacy Practice Notice 

Begin registration by printing and providing this HIPAA privacy information to each person with legal authority to consent to the patient's treatment.  This informational notice is to be kept for personal reference and is not returned to our office.

 

Next, click to open forms 2 through 5 which may be opened and completed, then printed and signed for return at or before the patient's first appointment. 

2.  Registration Form*  (By signing page 2 of the registration form, consent is given to release information directly to insurance for the purpose of billing and collecting payment from the patient's insurance.) Print Version

3. Signature Sheet for Receipt of Clinic's Privacy Policy* (Provides proof that the above HIPAA information has been received.)

4. Consent To Treatment*  (All medical patients require a consent to treatment. For minor patients, when parents are separated or divorced with joint custody/consenting authority, each adult must complete an individual Consent form and return it to our clinic for treatment/assessment of their minor child.)

5. Authorization for Release of Information Form*  (Individual release forms are needed for each entity that our clinic must contact, obtain information from and/or release information to during treatment and assessment.  Thus, it is common that multiple release forms are needed for each patient; e.g., it is common that 8 to 10 completed release forms are needed for minors receiving evaluations at our clinic.) 

 

Forms 6 does not apply to all patients - use as needed:

6. Payment Policy*  (To be completed for each medical patient unless covered by Medicare or Medical Assistance)