Black River

 

 

Downloadable Forms

A majority of the forms used in our offices can be easily downloaded as PDF files and are printer-friendly.

ACCOUNT OF DISCLOSURES

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

BA CONTRACT

BIOPSYCHOSOCIAL HISTORY

COMPLAINT FORM

CONSENT FOR TREATMENT - CHILD

CONSENT FOR TREATMENT - ADULT

DENIAL OF ACCESS TO PROTECTED HEALTH INFORMATION (PHI)

DENIAL OF REQUEST FOR AMENDMENT

FEE SCHEDULE

REQUEST FOR AMENDMENT OF HEALTH INFORMATION

HIPAA NOTICE OF PRIVACY PRACTICES

PATIENT'S RIGHTS

OFFICE POLICIES AND GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICES

AUTHORIZATION TO RELEASE INFORMATION

RELEASE OF INFO FOR ALCOHOL AND DRUG EVALUATION

CONSENT TO USE OR DISCLOSE INFORMATION FOR TPO

RELEASE TRACKING FORM

STANDARD RELEASE OF INFORMATION