| HIPPA AND PATIENT SERVICE AGREEMENT FORMS (These must be signed) |
| HIPPA Forms (available to all) |
| CPANCF Service Agreement Form |
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| RELEASE FORMS (Fill these out if you wish information to go out or come to us) |
| USE THIS FORM TO RELEASE RECORDS FROM SOMEONE ELSE TO US |
| USE THIS FORM TO HAVE RECORDS RELEASED FROM US TO SOMEONE ELSE |
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| HISTORY FORMS (Please complete the appropriate history form prior to your appointment - call office if you forgot password) |
| Child History Form Packet (password required) HIPAA form & Service Agreement |
| Adult History Form Packet (password required) |
| Adolescent History Form Packet (password required) parent form, HIPAA form & Service Agreement |
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| CITY OF GAINESVILLE EAP FORMS |
| Service Agreement |
| Intake Form |
| HIPAA Form |
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| Consent to Psychological or Neuropsychological Independent Medical Evaluation "IME" |
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| FILING YOUR OWN INSURANCE FOR OUT OF NETWORK BENEFITS |
| Instructions for filing your own insurance - sample Superbill |
| BCBS patients should complete this form with the superbill and submit the form to the address indicated. |
| Florida State EmployeeBCBS should use this form with the superbill |
| Federal Bluce Cross Blue Shield out of network Claim Form (file with superbill) (PDF) |
| Federal BCBS out of network claim form (en Espanol) (PDF) |
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| CONSULT FORMS (If you are a physician or other referall source) |
| Neuropsychology Services Consult Form (Microsoft Word) |
| Neuropsychology Services Consult Form (PDF) |
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| RESOURCES |
| Memory Help Websites, Reading, Computer Programs and Games - List (PDF) |
| City of Gainesville EAP Brochure1/28/2010 (PDF) |
| Download a Brochure of our General Services (PDF) |
| Alachua and Marion County Alzheimers Association Meeting Schedule |
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DOCUMENT FOR A RARE BREED OF FPA MEMBER
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DOWNLOAD OUR BROCHURES (all rights reserved, you may copy as long as no modifications are made)
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