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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