image
Google

The Web
cpancf.com




image   image
  Document Manager  

You may need free Acrobat Reader to open documents in PDF format.

 HIPAA AND PT SERVICE AGREEMENT FORMS   (these must be signed)
HIPAA FORMS (available to all)
 CPANCF SERVICE AGREEMENT FORM

 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
 
 HISTORY FORMS  (Please complete the appropriate history form prior to your appointment - call office if you forgot password)
CHILD HISTORY FORM PACKET (password required)  Child History, HIPAA form & Service Agreement
 ADULT HISTORY FORM (password required)
 ADOLESCENT PACKET (password required)  Teen form, parent form, HIPAA form & Service Agreement
 CITY OF GAINESVILLE EAP FORMS  1. Service Agreement    2. Intake Form   3. HIPAA Form

  Consent to Psychological orNeuropsychological Independent Medical Evaluation "IME"

 
  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
 

CONSULT FORMS- If you are a physician or other referall source, use this to forward a referral.

 Neuropsychology Services Consult Form  Microsoft Word format
 Neuropsychology Services Consult Form .pdf format
 
  RESOURCES
 Memory Help  Websites, Reading, Computer Programs and Games  - List .pdf format
 City of Gainesville EAP Brochure1/28/2010 . pdf file
 Download a Brochure of our General Services  .pdf file
 Alachua and Marion County Alzheimers Association Meeting Schedule

  DOCUMENT FOR A RARE BREED OF FPA MEMBER

 

   DOWNLOAD OUR BROCHURES (all rights reserved, you may copy as long as no modifications are made)

    

 

  



 

 
image   image
Gainesville Office: 2121 NW 40th Terr. Ste B. Gainesville, FL 32605  -   Phone: (352) 336-2888  -   Fax: (352) 371-1730
Ocala Office: 108 N. Magnolia, Suite 309, Ocala, FL 33475  -   Phone: (352) 629-1100   Email Us  Terms of Service  Privacy Policy