Please provide the following as best you can. I appreciate your willingness to cooperate in helping me obtain your history and information.
I authorize the release of any medical or other information necessary to process any insurance claim(s). I also authorize payment of medical benefits for services described on above mentioned claim(s). I understand that I am ultimately responsible for payment of all services rendered and that I will be charged for appointments if canceled with less than 24 hours notice. In order to utilize insurance, I understand that all copays must be paid at time of service.
Prior Mental Health History
Family History
Social History
Military History
Legal History
Medical History:
Summery
Purpose: Coordination of treatment.
I hereby authorize the release of the above information from my record. I understand that the information to be released from my record is confidential and protected from disclosure. I also understand that I have the right to cancel my permission to release information at any time before it is released. I also understand that my consent to release information will expire:
Use of E-mail Authorization
Many patients find it convenient and helpful to communicate with me by e-mail. While I welcome such communications, due to the inherent risks involved in e-mail use, it is important to understand the following:
Please provide a copy of a valid photo ID
Upload - scan and upload using the "Browse Files" button below
Fax to: 716-633-6902
Please provide a copy of your insurance card if applicable