Lakeway Psychiatry & Behavioral Health
Finding Your Path to Health and Happiness

Finding your Path to Health and Happiness



Patient Forms and References 


Required patient forms are provided below.

Forms are subdivided for your convenience, but if you have any questions, don't hesitate to call us!  


Click on the link to the right side of the chart to open the files

 New Patient Forms 
 
 
Patient Demographics
Form inquiring about basic information, your demographics, and contact information
Patient Clinical History
A detailed form inquiring about your past psychiatric, medical, social history along with current presenting problems
Patient Release of Information
Form to be filled by you and with your permission allowing our clinic to collaborate or obtain information/give information to/from individuals or entities including past psychiatric/medical practitioners
Patient Consent for Treatment 
Form to be read and signed in agreement to allow us to treat
Acknowledgment of Receipt of Notice of Privacy Practices
Form to be signed in acknowlegment of our privacy and confidentiality laws dictated by HIPPA and state/federal laws
Clinic Policies and Procedures
Form that outlines all the clinic policies and guidelines
Acknowledgment of Receipt of Clinic Policies and Procedures 
 Form to be signed acknowledging that you have read and accept the clinic policies and procedures
 Clinic Payment Policies
Form outlining all the pertinent payment policies
 Acknowledgment of Receipt of Clinic Payment Policy
Form to be signed acknowledging that you have read and accept the clinic payment policies
 Credit Card Authorization Form
Form to be signed to authorize any outstanding charges to be applied to credit card on file
 
 Established Patient Forms
 
 
Release of Information
Form to be filled by you and with your permission allowing our clinic to collaborate or obtain information/give information to/from individuals or entities including past psychiatric/medical practitioners
 ROI
Request for copy of personal record
Request for obtaining part or all of your medical record  
Changes to Personal Information
Form to be filled if there are any changes to personal information or if there are any anticipated changes

Click here to edit text

 Financial Forms
 
 
Request for Receipt of Payment for Insurance
 Form to be filled for submission to insurance for compensation
 Managed Care Private Contract Form
 Contract form that needs to be signed by patients under Medicare/Medicaid in acknowledgment/agreement of our policy prior to being seen
 Credit Card Authorization Form
Form to be signed to authorize any outstanding charges to be applied to credit card on file