New Patient Forms

New patients are invited to download the following forms before your first appointment. You can complete the forms and email, fax, mail, or bring the forms to your first appointment. 

Instructions
Insurance Claim Form: This is the 1500 standard form which will be sent to your insurance company for payment. Complete the upper right portion for the main card holder; and the upper right portion for the patient. If you are the main card holder and the patient still complete both sides. If you have a secondary insurance, complete the section under the patient information. 

Credit Card Authorization Form: Please complete this form carefully and sign. We maintain your credit card on file to charge for missed or late appointment cancellations, and for other services that you need that are not covered by insurance. Some of these are consultations with doctors, attorneys, court appointed persons, and the completion of disability forms.

Notice of Privacy Practices: This form is for your information regarding confidentiality; and you may keep it for your records.

Outpatient Services Contract: This form contains important information about Dr. McGowan, office practices; how therapy works and what to expect from the psychotherapy/counseling process. You should initial each of the statements where appropriate; and sign and date the contract. This contracts states the rules of confidentiality, office procedures and fees, and procedures to change or cancel an appointment. New patient cancellations, without 72 hour notice, will be charged $75. Established patients are required give a 48 hour notice to cancel appointments. Cancellations must be made by 1 pm, two or three days in advance. Cancellations should not be left on voice mail. Please call our office, so that we may offer your appointment to someone on our waiting list.

Patient Intake Form: Please complete this form for both the main insurance card holder, and the patient. Sign and date the form in two places at the bottom of the form.

You may request a copy of the Credit Card Authorization form; and the Outpatient Services Contract. It is important that you are familiar with the contract.
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Scottdale Psychological Services,
Dec 30, 2011, 11:38 AM
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Scottdale Psychological Services,
Dec 30, 2011, 11:38 AM
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Scottdale Psychological Services,
Dec 30, 2011, 11:38 AM
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Scottdale Psychological Services,
Dec 30, 2011, 11:38 AM
Ċ
Scottdale Psychological Services,
Dec 30, 2011, 11:38 AM
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