Name of Form

Instructions

Biography Form

Child   Adult

Fill out to the best of your ability. If a question does not apply just put N/A in the space provided. If you do not know the answer please answer don't know.

Statement of Confidentiality

This form needs to be read and signed my any person over 14 yrs old meeting with the doctor

Consent to Bill Insurance

The top half of this form needs to be filled out and signed by the insurance subscriber (or authorized person) to give our clinic permission to bill for services. If there is a second insurance fill out the bottom half of the form. We will require a copy of all insurance cards at the first appointment.

Acknowledgment of Receipt of Privacy Practices

It is required by law that we have this form on file. This form can be signed now and returned or can be completed at the time of your first appointment.

Payment and No Show Agreement

Print patient name and address and that of the responsible party at the top of the form. Sign and date the bottom.

Consent to Release to Primary Care Physician

This form is for your PCP's records. Fill out the first section. Choose any of the options in the center section, sign and date. The bottom of the form will be filled out after the appointment by Dr. Barber based on the level of authorized consent.

General Health History Form

 Please fill out to the best of your ability.  Put N/A if not relavent.