First Appointment Required Signatures

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Release of Information Consent for Insurance:

My signature below authorizes Innovative Psychological Consultants to exchange information with my current health insurance carrier in order to facilitate claims payment. I understand they will need to release my demographics, dates of service, diagnoses, and possibly my treatment plan and supporting information. I realize I can withdraw my consent at any time.
Clear Signature
MM slash DD slash YYYY

Confidentiality Notice:

My signature below indicates that I have read, received, and understand the limits of confidentiality for clients and healthcare providers in Minnesota.
Clear Signature
MM slash DD slash YYYY

Informed Consent:

My signature below indicates that I have been provided a copy of the Informed Consent Agreement. My signature below confirms my understanding of all the rules and responsibilities of both the client and the clinician. I have been informed and agree to adhere to the no show and late cancellation policy. My signature constitutes my agreement and compliance with the document.
Clear Signature
MM slash DD slash YYYY

Federal Guidelines on Confidentiality:

Please indicate below whether you would like a copy of the Federal guidelines on confidentiality: Health Insurance Portability & Accountability Act (HIPAA).
Agreement*

Communication with Primary Care Physician:

Many clients, and insurers, like their clinicians to communicate and share information with primary care physicians. Please indicate below if you would like us to contact and send a copy of your assessment to your physician.
Agreement*