You must arrive 15 minutes prior to your scheduled appointment. Please bring with you the following: Insurance card, ID and completed forms. If your appointment is for a child, please make note that a portion of the visit will be with the parent or guardian without the patient present. Please provide supervision for your child, should you feel necessary.
Please Complete the following forms using Adobe Reader which can be downloaded free here. These forms require a digital signature which can not be completed in a web browser.
Instructions on how to open the forms, fill them out, and submit them can be found here.
Release of Medical Information Request Form: Patient privacy is a priority in our office. This form allows you to indicate how you prefer to be contacted. Please indicate on the form any and all numbers you would like for us to contact you at. If you would like us to call this number you must also check off that it is okay to leave a voice mail or message with the person answering. In addition, please indicate how you prefer to receive your confirmation calls. Please only choose one option.
RELEASE OF MEDICAL INFORMATION REQUEST
Outpatient Services: This is your consent to treatment. This document contains critical information that you as the patient should be aware of. Signatures are required by all those participating in treatment. If patient is a child, parent/guardian must sign (if biological parents are not married both parents must sign unless prior approval obtained). If patient is 14 or older, both patient and parent must sign (if biological parents are not married both must sign). If therapy is for couples, both parties must sign, and family all members must sign.
Our Financial Policy is also included in this contract. As you can see our policy requires you to provide your credit card information. This is kept in your patient file and is as protected as your medical information. We will only use this card for any patient balance that has accrued over 30 days from the date of the statement. Our office will provide monthly billing statements and remind you that this balance will be charged to your credit card if not paid within 30 days.
Treatment Contract and Financial Policy
Notice of Privacy Practice:This information is for you to keep. It explains the Health Insurance Portability and Accountability act of 1996 (HIPPA).
Magellan Forms: If your insurance is Magellan you must also complete the attached two forms. To complete the Magellan Behavioral Health Members’ Rights and Responsibilities Statement you must sign at the bottom. To complete the Authorization to Disclose Protected Health Information to Primary Care Physician Form you must complete Section 1 with your personal information and check a box next to “I am.” In section 3 you can provide us with your primary care physician information if you would like for us to disclose to your doctor that you are receiving treatment or you can write refused. Please sign the form. If you have completed the information for your PCP and the the patient is 14 years or older they must also sign as well as both parent/guardian if parents are not married.
Members Rights and Responsibilities Statement
Release Of Information Therapist To Therapist:
RELEASE OF INFORMATION Therapist to Therapist
Telemental Health
To Join a Telehealth appointment please select the team member below.
Donnalee Snyder, MA, LPC, LCADC, CRC
Telemental Health Forms