Before your/your child's initial evaluation, I will need you to fill out, sign, date, and send in (by email or fax) the background information survey, the Treatment Agreement, and the Notice of Privacy Practices. Coordination of care is at the core of successful treatment of children's issues, and so I will also need you to fill, sign, date and send me a release of information authorizations for any current providers, your pediatrician or primary care doctor, and your school. Children 14 and over should also sign the release of information forms.
I will scan the completed documents into your/your child's medical record.
The Treatment Agreement and Release of Information documents will need to be re-authorized with your signature annually.
The Treatment Agreement is a required form that specifies policies related to payment, confidentiality, cancellations, and much more. There are seperate forms for treatment agreement for minors and treatment agreement for adults.
Please fill out this Background Information Form and send it to me by email, fax or mail before our first meeting.
Use Release of Information forms to authorize contact between Family Psychiatry of Maine and your/your child's other current and past health care providers, therapists, schools, etc.
The Notice of Privacy Practices Acknowledgement describes how we store, use and share protected health information. You are required to sign the acknowledgement page.
Insurance Reimbursement Worksheet helps you get the information you need from your insurance carrier to get reimbursed.
The Email and Text Messaging Consent Form allows you to authorize communications via these convenient, but not completely secure, methods.
Disclaimer: The information on this website is intended for your information and education. It is NOT to be used as specific medical advice for you. I will be happy to discuss your particular, individual situation with you if you decide to become a patient.
Note: To download Adobe Acrobat Reader for free, click here.