Forms

Medical Forms for Our Behavioral and Psychiatric Services

Please feel free to upload or fax any forms from below "Choose File".
New patients: Please sign & upload Forms (1-4), and also upload Items (5-6).
If you can't upload, please fax over to 631-930-3231

Psychiatry Clients

1-Registration & Insurance
2-Notice of Privacy Practices
3-HIPPA Consent
4-Telehealth Consent
5-Upload Insurance ID (front & back) Card
6-Upload Driver License Card
7-Physical Clearance For PCP
8-Permission To Treat Minor

TMS Clients

1-Registration & Insurance
2-Notice of Privacy Practices
3-HIPPA Consent
4-Telehealth Consent
5-Upload Insurance ID (front & back) Card
6-Upload Driver License Card
7-Physical Clearance For PCP

Suboxone Clients

1-Registration & Insurance
2-Notice of Privacy Practices
3-HIPPA Consent
4-Teleheatlh Consent
5-Upload Insurance ID (front & back) Card
6-Upload Driver License Card
7-Physical Clearance For PCP

UPLOAD or FAX 631-290-3231