Patient Registration Form: Serves to collect basic demographic information including financial responsibility and emergency contacts.
Patient Contract: Outlines our office policies in detail highlighting areas such as confidentiality, release of personal information, provider availability, fee schedule and cancellation policies.
Telephone Policy: Describes our policy on telephone contact including contact initiated via Skype, email and text message.
Notice Of Privacy Practices (HIPAA): Serves as a reminder of your rights to privacy, under the Health Care Information Portability and Accountability Act.
Authorization for Release of Information: This form outlines who needs to be contacted regarding your case. Important individuals often include family members, previous clinicians, teachers, primary care doctors, etc. Please remember that you are always in charge of who receives information and who is included in the treatment process.
Credit Card Authorization: Dr. Ozbolt will hold appointment times for you in her schedule, and in return requests that you fill out this form. She will only charge your credit card in the following situations: (a) cancellation less than 48 business hours in advance of your appointment, (b) no show for appointment, (c) additional services rendered agreed upon by you (i.e, phone sessions, report writing, etc.), and (d) lack of payment for appointments.