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Patient Health and Insurance Form

Note: Please fill in your Full Name and Email carefully. These will appear on all subsequent pages.

Basic Information

Employment Status
How did you hear about us?

Mental Health Information

I. Reason for Seeking Care

II. Risk Assessment

Services Requested

Preferred Location

Healthcare Information

Primary Care Provider

Pharmacy

Insurance Information

Current Medical List

Current Medical List

Name (brand or generic) Indication (What are you taking this for?) Dosage (mg) Schedule (daily, twice daily, etc.) Who Prescribes this? (Name/Specialty)

Medical Health History

Note: This page is optional. However, please be advised that any missing information will be reviewed with your provider during the initial evaluation, which may affect treatment decisions made on evaluation day.

Patient Medical Health History

Condition Check if applies Explanation (if applicable)
Drug Allergies
Asthma
High Blood Pressure
High Cholesterol
Kidney or Liver Dysfunction
Heart Disease
Cardiac Arrhythmia
Seizures
Glaucoma
Diabetes
Genetic Diseases
Cancer
Chronic Pain
Sleep Disorders
Learning/Developmental Disorders

Reproductive and Hormonal Health

Mental Health Treatment History

Mental Health Treatment History

Past Mental Health Medication Trials or Psychiatric Treatments

Medication/Treatment Name Date(s) Taken Response Other Comments

Modified Mini Screen (MMS)

Patient Details

Section A

Please answer "Yes" or "No" to the following:

Section B

Section C

Family Mental Health History

Note: This page is optional. However, please be advised that any missing information will be reviewed with your provider during the initial evaluation, which may affect treatment decisions made on evaluation day.

5. Family Mental Health History

To the best of your knowledge, please indicate whether there is a family history of the following:

Condition Known Diagnosis Suspected Diagnosis / "Trend" Affected Family Member Not Applicable
Depression
Anxiety
Bipolar Disorder
Schizophrenia
Suicide attempts or death by suicide
Psychiatric hospitalization/institutionalization
Substance concerns
ADHD
OCD
Other (please specify)
Penfield Psychiatry - Consent Forms

Consent Forms

Patient-Provider Agreement

OVERVIEW

Penfield Psychiatry is a Private Practice we are a group of mental health providers comprised of therapists, psychologists and prescribing providers (Nurse Practitioners -NPs, Physician Assistants-PAs, and Medical Doctors-MDs) our group offers psychotherapy, testing diagnostic evaluations and medication management services all under one umbrella, including latest treatments like Spravato and Transcranial Magnetic Stimulation. Please refer to the practice’s main website to review all available services: this may be subject to change.  
Our practice is not a community clinic. We do not offer walk-in appointments, chemical dependency treatment or associated Medication Assisted Detox Treatment, nursing services, or emergency services.  
Penfield Psychiatry accepts self-pay and specific insurances. Insurance coverage questions may be answered by contacting the main office phone or email address.  
 
Penfield Psychiatric is open Monday through Friday 9:00AM - 4:00 PM.  
The office is closed 12-1 PM for lunch.  
Please see holiday closing announcements on our website homepage
Phone: (585) 388-6000 
Fax: (585) 388-6004 
Main Email Address: info@penfieldpsych.com	 
Website: https://penfieldpsych.com/ 
Physical Address of our Main office: Penfield Psychiatry 
2060 Fairport Nine Mile Point Road; Suite 400 
Penfield, NY 14526 
We additionally have offices in Farmington, Ithaca and Albany where we offer limited services.  

MEDICATION MANAGEMENT APPOINTMENTS 
Medication management services begin with a minimum of a 60 minute psychiatric evaluation to review mental health history and diagnostics. It is not uncommon to require a subsequent 60-minute session for ongoing data-gathering (such as collateral from family, other treatment providers, academic instructors and or hospital discharge). These sessions are necessary to ensure appropriateness for level of care. If the level of care does not meet the clients current medical needs we will provide other community resources to find appropriate level of care.  
Patients accepted to a prescribing provider’s practice would then schedule subsequent medication management follow-up appointments. These are typically 30 and sometimes 15 minutes with focus on treatment planning with medication. Follow-up appointments may be every few weeks to once a month, particularly in the beginning of treatment. When a patient is feeling “stable,” they are considered in “maintenance” phase for medication management: best practice recommendations are to still maintain follow-up appointments every monthly. This recommendation is evidence-based: studies suggest regular attendance intervals help proactively reduce risk of mental health worsening and crisis through careful monitoring, patient ability to better understand and manage mental health concerns, and a trusting therapeutic relationship with a prescribing provider.  
 
THERAPY APPOINTMENTS 
Therapy sessions begin with 60-minute intake evaluation sessions. Subsequent sessions may be 45-60 minutes long to continue information gathering for 1-3 sessions, before ultimate determination to admit to practice. In these sessions, diagnostic criteria is reviewed as well as establishment of coping skills, safety planning, and psychotherapy modality and related planning.  
Once a patient is accepted to psychotherapy, the same billing and attendance for in-person and telehealth standards are applied (as described below).  
Follow-up psychotherapy sessions may be every week to every few weeks: interval / frequency is determined between patient and provider. 
 
Appointment Format: In-Person and Telehealth 
Penfield Psychiatry offers both in-person and telehealth sessions. Some providers offer both in-person and telehealth options, whereas other providers offer one or the other.  
Regular attendance for follow-ups are essential to ensure continuity of care, track progress, and address emerging challenges in a timely manner: this reduces the risk of feeling worse or experiencing a crisis. 
 
 Telehealth appointments are video-based sessions through the doxy.me  platform. Providers must know where you are and if someone is with your for documentation purposes. Please be in a safe, quiet location. It is important to have good internet connection for the video call. Should the video call experience technical issues, your provider will discuss their preferred mode to switch to for session completion.  


Inviting Others into Session 
Therapy and medication management sessions are individual treatment sessions, 1 patient to : 1 provider, unless otherwise specified by your provider (ex/ couples counseling). Providers often welcome a patient’s request to include a trusted support to be involved in their treatment. Please keep in mind that the time and complexity of the visit may increase for  the number of individuals a provider may be educating and holding session. However, there may be times when a provider may respectfully request others not be part of the treatment session, if there is concern that other participation seems to interfere with the treatment process. Your provider will offer explanation in these circumstances.  


Appointment Attendance:  

Lateness 
If patients are late to their scheduled appointment time, it is provider discretion to end the appointment at the scheduled time or to extend time as available.  
If providers are running late to appointments for patients, often providers will offer the minimum time (therapy: 45 minutes; medication management: 15 minutes) for that session — and if/when possible, offer extended time.  
*There are situations where sessions may “run over time.” Please be aware this may be an indication of time/complexity for billing purposes. Please also be mindful that another person may be scheduled right after you. Providers may ask if a session is running over, to “continue the conversation” and scheduling a sooner follow-up. Providers may also request that patients block more time for sessions to avoid “running over.”  


No Shows / Late Cancellations 
Penfield Psychiatry will charge no show fees for missed appointments (no call, no shows). Patients who cancel with less than 24-hour notice may be charged a late-fee, barring emergency. 
Please try to reschedule as soon as possible, or per your provider’s rescheduling protocol if different from this document, to ensure there is regular mental-health check-ins and no barriers to receiving medication refills. 
It is necessary for patients to be seen regularly for appointments to be considered “active” on any provider’s caseload, and in order to safely prescribe medications. 
*Please see the billing section for fee schedule.  


Ending Care 
Patients who have not been seen in 3 to 4 months with no response to contact/outreach to Penfield Psychiatry’s office will be presumed as lost to contact and the office will begin formal discharge procedures to close that patient’s chart. 
If a patient feels they have met goals, or would like to end treatment for any reason, it is best to have a final appointment to discuss ending of treatment and ensure proper request for a standard final 30-day medication refill. Please note, if another provider has already taken over care, it is not required of the Penfield Psychiatry provider to provide an additional refill, as this would be duplication of service.  
Otherwise, please notify staff at the main office number of intention to close care. Medical records will be available through formal request with ATTN to: Medical Records. 


COMMUNICATION STANDARDS 
A Release of Information (ROI) is requested for prescribing providers to coordinate care and send initial evaluations to: PCPs; MH therapists; any other pertinent provider to your psychiatric care, as well as family members. 
 
Notice for Email: 
It is patient responsibility to review all email disclaimers below signature of emails regarding privacy/confidentiality information. Email may be used for purpose of sending information to patients or to receive specific information from patients (refill requests, records/results). 
Direct provider emails may not be regularly monitored: it is asked that patients please use the main email address for regular screening and response. 
 
Nature of emails should be brief: emails should not be used to convey urgency/ crisis or ongoing treatment planning (detailed information): providers who receive emails with Personal Health Information (PHI) details and additional questions may have an auto-reply with an email signature requesting patient matters be addressed in a scheduled appointment. Please know your email content will be uploaded to your patient chart. Ex/ medication change requests will only be made with an in- appointment assessment. 


Notice for Returned Patient Phone Calls:-Providers may return calls when it is anticipated there will be a brief but necessary discussion that cannot wait until a scheduled appointment. Sometimes, phone calls may go longer due to the nature of the call. Please be aware phone calls may be billable services dependent on time and complexity. 
 
Excessive Communication: In some instances, patients may have situations that arise that require frequent contact for a short-term period of time in order for a resolution of a clinical matter. However, it is a reflection that a private practice level of care may not be suitable for a patient should there be persistent, excessive communication that does not seem clinically pertinent to the case. All providers will directly speak with patients who may be using excessive communication.
  
MEDICATION REFILL REQUESTS 
Typically, refills are addressed during scheduled medication management appointments: patients and prescribers will determine amount to refill to coincide with the next follow-up appointment.  
 
Certain refill requests may not be authorized for refill without first seeing the prescriber: this is usually due to need to schedule follow-up appointments.  
 
However, it is sometimes the case that refills are not neatly lined up with follow-up appointments. Patients are asked to understand the following for refill requests:   
Please review your prescription bottle and review the number of refills: if it says “0” then please call Penfield Psychiatry for a new prescription. If there is a number “1/2/3” next to the word refills, this indicates there are still refills on the current prescription that you can pick up at your pharmacy.  
If you run out of medication and require a refill before your next appointment, please: - call (585) 388-6000 or email info@penfieldpsych.com stating NAME; PHARMACY; MEDICATION when requesting refills. 
*Please indicate if you get 30 or 90 day refills* Allow 1-5 business days to process. 
*Patients 18 years or younger must also provide HEIGHT and WEIGHT — this is required for submitting medications.  
*Some medications may require PRIOR AUTHORIZATIONS: this can further delay the refill/pick-up process. Please know these cases can take up to 5 business days to process.  
Please: Be mindful that it is patient responsibility to request refills in a timely manner. Late requests may result in a few days without a medication due to processing requests from office-to-pharmacy.
  
EMERGENCIES 

Urgent Needs and Emergencies 
Urgent needs and Emergencies do come up: what is the difference?  
Urgent issues are not life-threatening, and while “prompt” attention may be needed, concerns do not need to be addressed “immediately.” In these cases, a patient may have a life situation come up or a side effect to a medication they need to discuss urgently with their provider. Patients can contact and anticipate a same-day response.  
Emergency needs are often considered crisis situations. This is when a person experiences major symptoms, life upsets, and may be experiencing thoughts of harming themself or others. The person needs immediate attention and should not wait for someone to respond to them.  
Please note that providers may not be able to answer the phone during general office hours. Due to this, in times of crisis, patients are directed to utilize crisis/safety plans and local resources. 
*If you are calling due to urgent needs outside of office hours, Penfield Psychiatry has an AFTER HOURS number: please call (585) 388-6000 and listen to the prompts to connect to the After Hours Operator, who will then connect you to the on-call provider. 
If you require a providers that is more available, or your provider determines that their hours of availability do not fit your current needs, that provider will discuss the appropriateness of a referral for a higher level of care, or discharge. 
Crisis Service Information 
MENTAL HEALTH EMERGENCIES 
-Call 911 
-Lifeline 2-1-1 
-Go to your nearest Emergency Department 
-Call 988 to reach a crisis counselor 24/7 
-URMC Mobile Crisis: 585-529-3721 
 
In the Rochester area, you may also go to: 
 Behavioral Health Access and Crisis Center (BHACC) 
 65 Genesee Street -- Entrance at 11 Chili Avenue 
 Daily walk-ins 9am-9pm no appt necessary: (585) 368-3950 
PHYSICAL EMERGENCIES: Please go to your nearest Emergency Dept. 
BILLING INFORMATION and FINANCIAL POLICY 
Billing codes and late fees are standard to the practice at large. As such, all billing/ payment matters are handled by the Penfield Psychiatry administrative staff. 
Please remember: sessions are not always “the same” in time and complexity and may vary in coding/cost. Medication management services are billed by complexity and time. Depending on this, you may see two codes on your statement: particularly a 90833 code. 

Payments 
-Bills are expected to be paid AT TIME OF SERVICE. 
-A late-fee of $15 will be added after 30 days of an unpaid bill 
-Our billing department will reach out to patients between 45-60 days if accounts are not in good standing, to identify a payment plan. 
-If accounts are not paid within 60 days, or there is failure to comply with payment plans, accounts will go to collections. 
-Treatment cannot continue for patients with accounts that are not in good-standing as this is a breach of the patient-provider agreement to pay for services in a timely manner. 
 
Please see the below explanation regarding this secondary code. Any other questions regarding billing can be addressed with Penfield Psychiatry’s billing department, and/or during a scheduled appointment. 

How Does Penfield Psychiatry Enhance Medication Management Services? 
Using CPT Code 90833 to Improve Quality of Care Medication management is not a one-size-fits-all service. Effective treatment requires prescribers—who may not always be the same as your therapist—to gain a comprehensive understanding of each patient's unique mental health challenges. For instance, some antidepressants can aid in smoking cessation, improve learning disabilities, or may be better suited for women planning to become pregnant. By engaging in meaningful discussions during medication management appointments, our prescribers can make more informed decisions regarding the most appropriate medications. 
 
Utilizing CPT Code 90833 transforms medication management appointments from standard 15-minute check-ins into comprehensive 30-minute sessions. This additional time allows for: 
 
• In-depth Conversations: We engage in detailed discussions about your mental health status. 
• Coping Strategies: Our providers offer practical tips for navigating challenging situations. 
• Building a Treatment Alliance: We prioritize developing a trusting relationship between patient and provider. 
• Comprehensive Assessments: We discuss a range of mental health issues that may affect the patient. 
• Medication Issues: A thorough exploration of medication-related concerns and options. 
 
By dedicating time to understand the patient’s mental health issues holistically, our prescribers can establish stronger, more open relationships and make informed medication choices tailored to each individual's needs. However, offering this level of care does present billing and insurance challenges.  
That’s where CPT Code 90833 plays a crucial role. This add-on code allows mental health providers—including psychiatrists, nurse practitioners, physicians, and physician assistants—to extend their consultation time to 16-37 minutes without compromising the quality of care. 
 
Why is CPT Code 90833 Important? 
 
This code is pivotal in enabling us to provide enhanced medication management services. Here are a few key benefits: 
Increased Quality of Care: By allowing more time for thorough assessments and discussions, we can offer a more holistic approach to medication management. 
Enhanced Patient Satisfaction: Patients feel valued and heard, as they have the opportunity to voice concerns and ask questions without feeling rushed. This fosters a sense of importance and engagement in their treatment. 
Successful Treatment Regimens: A comprehensive and attentive approach contributes to a more effective treatment plan over time, ultimately improving health outcomes. 
 
CPT Code 90833 is not just about prescribing medication; it embodies our commitment to listening to our patients and treating mental health with a holistic perspective. We believe that this approach is essential to providing the top-notch care that our patients deserve. 
 
Missed Appointments NO SHOWS/LAST MINUTE CANCELLATIONS: 
Please be advised that Penfield Psychiatry has a strictly enforced missed appointment policy. The normal charge for the service will be billed directly to the patient/client. We require that you contact our offices 24 hours in advance during the business week to cancel or change your appointment if need be. If you are scheduled with a prescriber, you should call the office or email well in advance, and if you are scheduled with a therapist, you should contact them directly.  Prior to your next appointment, this fee must be paid.  
 
 
Financial Policy   
Your financial responsibility is due at the time of service.  We accept cash, some credit cards and checks with a valid driver’s license.   
-If your insurance policy requires preauthorization for a service and you do not have that authorization information, you will be responsible for payment of the full fee at the time of service.   
-If your insurance denies a claim because there is no initial authorization, you are responsible for payment of the entire fee.  
Because of our contracts with insurance companies, we are unable to provide service without charging you the portion for which you are responsible.  All overpayments are credited to your account and will be held and applied as needed until all services have been paid in full.  Remaining overpayments will be applied against future services, unless the overpayment is at least $20.00 and you request reimbursement.   
 
OFFICE PRIVACY POLICY 
For the protection of our patients/clients and staff, any activity that may be considered an invasion of privacy while in our offices will result in discharge of the offender from our practice. These activities include, but are not limited to, photography, recording of conversations, or similar behavior. Charges will be fully pressed against the offender of the law. 
 
PATIENT CODE OF CONDUCT 
 
All Penfield Psychiatry staff, at all locations, will provide professional, ethical, and compassionate care. Please be advised of our patient expectations:  
 
-Patients will comply with environmental safety: No Weapons are allowed on Penfield Psychiatry premises (guns, knives, etc.).  
 
-Patients will communicate respectfully, whether this is in-person, over-the-phone, or via email: Verbal intimidation - yelling, swearing, threats, or physical intimidation- aggressive gestures, standing close, throwing objects, will not be tolerated.  
 
-Patients will report accurate information about their health history: misrepresentations may be a breach in the treatment relationship and will be addressed.  
 
-Patients will pay bills in a timely manner, and address billing matters with the billing department: accounts in default may result in collections.  
 
-Patients will adhere to appointment scheduling and attendance standards: lack of treatment engagement may affect ongoing care.  
 
 
Patients who are in violation of the Patient Code of Conduct are subject to dismissal from the practice. 
 
 
TERMINATION OF TREATMENT 
 
In addition to the above agreements, I accept the right of my provider's staff to terminate this agreement for any of the following reasons: 
 
a)	I seek or obtain any PSYCHIATRIC medication from a source other than my provider. 
b)	I in any way attempt to forge or alter a prescription. 
c)	I distribute my prescribed medication(s) to any other person. 
d)	My medical condition declines to the point at which, in the judgment of my provider, continued therapy with this medication or level of care presents danger to my wellbeing or safety. 
e)	There is evidence that I am no longer receiving a reasonable therapeutic benefit from the medication, or  my provider determines that I am no longer a good candidate to continue the medication or level of care. 
 
I understand that by signing this agreement, I must abide by the rules reviewed above and that failure to abide by these agreements will result in termination of medication prescriptions and immediate dismissal from my provider and the practice. 
 
I understand that if I default from this agreement and I am having a medical condition I should call 911 or go to the nearest emergency room.  
 
 
_________________________________________ 
               	Patient/Client Signature		                                
 
 
_____________________________________           
 
 Signature of parent / guardian responsible for minor child or dependent adult 
 
Date: ____/____/______ 
 
 
Thank you for your continued support and dedication to enhancing the quality of care at Penfield Psychiatry. 


                                

Authorization for Release of Health Information Pursuant to HIPAA

Legal Disclaimer:

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:

  1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a).
  2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law.
  3. I have the right to revoke this authorization at any time by writing to the health care provider listed below.
  4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
  5. Information disclosed under this authorization might be redisclosed by the recipient and this redisclosure may no longer be protected by federal or state law.
  6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED.

Penfield Psychiatry, 2060 Fairport Nine Mile Pt. Rd., Suite 400, Penfield, NY 14526

30 days post discharge

Rochester RHIO Consent Form

I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow the above-named Provider Organization or Health Plan to obtain access to my medical records through the health information exchange organization called Rochester RHIO.

If I give consent, my medical records from different places where I get health care can be accessed using a statewide computer network. Rochester RHIO is a not-for-profit organization that shares information about people's health electronically and meets the privacy and security standards of HIPAA and New York State Law. To learn more visit Rochester RHIO's website at www.RochesterRHIO.org.

My information may be accessed in the event of an emergency, unless I complete this form and check box #2, which states that I deny consent even in a medical emergency.

The choice I make in this form will NOT affect my ability to get medical care. The choice I make in this form does NOT allow health insurers to have access to my information for the purpose of deciding whether to provide me with health insurance coverage or pay my medical bills.

By entering your full legal name, you are signing this agreement electronically. You agree you are the patient or the patient's legal representative, authorized to sign on the patient's behalf.

If you are signing for the patient, please state relationship. If you are the patient, enter "Self"

Telehealth Consent

I hereby consent to participate in telemental health with Penfield / Finger Lakes Psychiatry. I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.

I understand the following with respect to telemental health:

  • I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits.
  • There are risks, benefits, and consequences associated with telemental health, including disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
  • There will be no recording of any online sessions by either party. All information disclosed within sessions and written records are confidential.
  • Privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies.
  • If I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, telemental health services may not be appropriate.
  • During a telemental health session, we could encounter technical difficulties resulting in service interruptions.
  • My therapist/nurse practitioner may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

Emergency Protocols: I need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life-threatening emergency only.

Controlled Substance Agreement

We are committed to doing all that we can to treat your psychiatric conditions. In some cases, controlled substances are used as a therapeutic option in the management of such disorders, which is strictly monitored by both state and federal agencies. This agreement is a tool to protect both you and the prescriber by establishing guidelines, within the laws, for proper prescribing practices.

Agreement Terms:

  1. I will inform my prescriber of all medications I am taking, including over the counter medications, herbal remedies and medications from other prescribers, including my PCP. I will not seek prescriptions for my psychiatric medications from any other physician without our office's knowledge.
  2. All controlled medications must be obtained at the same pharmacy, where possible. Should the need arise to change pharmacies our office must be notified.

Additional Terms:

  • You may not share, sell or permit others to use your medications, including family members, spouses, friends, co-workers, etc.
  • Unannounced serum, oral swab or urine toxicology screens may be requested from you and your cooperation is required.
  • Medications may not be replaced if they are lost, stolen, get wet, are destroyed, left on vacation, etc.
  • Early refills will not be given. We request 5 business days for all prescription refills and that you keep all scheduled appointments.
  • I will not consume excessive amounts of alcohol with my medications. I will not use, purchase or obtain any other legal drugs without knowledge and approval from my prescriber.
  • I understand that failure to adhere to these guidelines may result in my medications not being refilled and furthermore, discharge from this practice.

Privacy Practices Acknowledgment

I hereby acknowledge that I have received and have been given an opportunity to read a copy of privacy practices for Penfield Psychiatry/Finger Lakes Psychiatry.

I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Penfield Psychiatry/Finger Lakes Psychiatry.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

If you are signing as a personal representative of an individual, please also describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.).

Final Consent and Signature

Patient Document Upload

Note: Please ensure all uploaded documents are clear and legible. Accepted formats: JPG & PNG.

Required Documents

Insurance Card (Front)

Please upload the front side of your insurance card

Insurance Card (Back)

Please upload the back side of your insurance card

Driver's License

Please upload a clear photo of your driver's license
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