Consent Form for Telehealth

This 2-page PDF document is required for compliance with current laws that protect privacy and confidentiality which also apply to Telemental health services. Exceptions to confidentiality are described in the Notice of Privacy Practices that FPS uses. Telemental health services are provided through a HIPAA compliant and secure platform. No permanent video or voice recordings are kept from Telemental health sessions. Client may not record or store video from sessions.

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Consent Form for Telehealth  

Privacy Practices & HIPAA Form

This 6-page PDF document (including one-page form) is a required "notice of privacy practices" (NPP) in keeping with Federal HIPAA (Health Insurance Portability and Accountability Act, 1996) requirements. Click to download.

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Privacy Practices & HIPAA Form 

Initial Patient Information Form

Two-page form in PDF format: Name, address, phone, Emergency Contact Information, Receipt of Notice of Privacy Practices. Click to download.

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Initial Patient Information Form 

Medical Billing Information Form

One-page PDF form: Primary Care Provider, emergency contact info, insurance information.

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Medical Billing Information Form

Medical History Form

Download Medical History Form,

Medication Information

1	Medline Plus
2	Patient Assistance Program
3	The Healthy Place

Alternative Treatments

ADHD

12 Step Programs

Recommended Chiropractors