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  • English (US)
  • Richard L. Azrin, Ph. D.

    Cheryl Millsaps Azrin, Ph. D.
    Leslie Kahn, LCSW

    Amber Fox , LPC
    4260 Cahaba Heights Court Suite 180
    Birmingham AL, 35243
    Voice: (205) 329-7815, 
    Fax: (205) 329-7816

    jamie.bhamneuro@gmail.com
    www.brookwoodclinic.com

     

    1. Please complete as much as possible of these forms.
    2. You may skip any items that don't apply
    3. Be sure to hit Submit at the bottom of the form, in order for us to get your answers.

    Please sign all of the following 3 forms:

    Form 1) The first form asks for your contact and insurance information.

    Form 2) The second form asks who we can obtain information from and release information to.

    Form 3) The third form gives us permission to do telephone or video calls with you. 
     

  • Form 1: New Patient Information



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  • Request for Confidential Handling of Health Information
    Complete alternate contact information below only if you want communications regarding your health care information sent to an alternate address or telephone or email, other than listed above.  I request that my provider handle my confidential health information as described below.  All reasonable requests to receive communication of your health information by alternative means and/or locations will be granted.  Please describe the alternative means below (e.g. US mail, telephone call, Email, etc.) by which you prefer to receive your health information.

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  • Agreement
    If your insurance company OR health plan requires pre-approval OR referral for your visit, it is your responsibility to obtain this referral or YOU will be personally responsible for the bill. I, the undersigned (patient or legal guardian), authorize medical treatment to be rendered by the provider and assume financial responsibility. In the event the account is not paid in full within 90 days*, the undersigned agrees to pay all costs of collection including reasonable attorney  fees, and hereby waives all rights of exemption under the constitution and laws of the State of Alabama. I also authorize the release of my medical records to my physicians and insurance carriers. If the provider has a contractual arrangement with your insurance carrier, the balance refers only to the amount that you are required to pay. I understand that all of the providers in the offices at 4260 Cahaba Heights Court, Suites 180-182, Vestavia, AL 35243 are independent practitioners (not partners) although they are sharing office and staff. Your signature below also indicates you have seen or received the Alabama Notice Form: Notice of Policies and Practices to Protect the Privacy of your Health Information and agree to its terms and serves as an acknowledgement that you have been shown or given a copy of the HIPAA Notice Form.
    COMMUNICATION REGARDING MY ACCOUNTS: Until my accounts are finally settled, I give my direct consent to receive communications regarding my accounts from any services and any collectors of my accounts, through various means such as 1) any cell, landline, or text number that I provide, 2) any email address that I provide, 3) auto dialer systems, 4) Voicemail messages, and other forms of communication.
    Informed Consent: I agree to participate in evaluation/treatment, and the purpose has been explained to me and/or my guardian/representative.

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  • Form 2: Release of Information

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  • DO NOT LIST YOUR OWN NAME BELOW. 

    PLEASE LIST FAMILY, DOCTORS, OR HOSPITALS YOU WOULD LIKE ME TO OBTAIN INFORMATION FROM AND RELEASE INFORMATION TO.

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  • Form 3: Consent for Teletherapy, Video, and Audio

  • Teletherapy Video and Audio Consent Agreement
    I understand that telehealth or teletherapy involves the use of electronic information and communication technologies by a health care provider to deliver services to an individual when they are located at a different site than the provider; and hereby consent to receiving health care services to me via telehealth over secure video conferencing platform. I understand that the laws that protect privacy and the confidentiality of my medical information also apply to telehealth or teletherapy. I understand that while telehealth or teletherapy treatment has been found to be effective in treating a wide range of disorders, there is no guarantee that all treatment of all clients will be effective. I understand that there are potential risks involving technology, including but not limited to: Internet interruptions, and technical difficulties. I understand that technical difficulties with hardware, software, and internet connection may result in service interruption and that the health care provider is not responsible for any technical problems and does not guarantee that services will be available or work as expected. I understand that I am responsible for information security on my computer and in my own physical location. I understand that I am responsible for creating and maintaining my user name and password and not share these with another person. I understand that I am responsible to ensure privacy at my own location by being in a private location so other individuals cannot hear my conversation. I understand that my health care provider or I can discontinue the telehealth/ teletherapy services if it is felt that this type of service delivery does not benefit my needs. I have read and understand the information provided above regarding telehealth or teletherapy, have discussed it with my health care provider or office staff and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth or teletherapy in my care.

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  • If you don't know your copay, please call 205-329-7815 from 8am-noon or from 1pm-4pm to pay your copay before your upcoming visit.

    IF YOU DON'T KNOW YOUR COPAY DO NOT ENTER CREDIT CARD INFORMATION
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