NEWPORT BEACH BEVERLY HILLS PASADENA LAGUNA BEACH
949.891.0307
310.988.9393
626.723.3099
949.391.4669
TERMS
Notice Of Privacy Practices (HIPAA): Serves as a reminder of your rights to privacy, under the Health Care Information Portability and Accountability Act.

Our Privacy Practice Signature Form: Please sign the above “Notice of Privacy Practices (HIPAA).”

Treatment Consent: Provides information about various treatments including psychotherapy and medication management. Please read carefully and sign prior to your first visit.

Insurance Information Form: Please be aware that Dr. Davis does not accept any form of insurance reimbursement and is not contracted insurance providers with any company. Should you elect to pursue reimbursement from your insurance company for his services he can provide you with a billing statement.Dr. Davis requests the following information to assist in helping you with your insurance company's medication authorizations should they become necessary.

Consent for Release of Information: This form is very important if there are others that need to be contacted regarding your case. Important individuals often include family members, previous clinicians, teachers, primary care doctors, etc. Please remember that confidentiality is a pillar of mental health care. Therefore, you are always in charge of who receives information and is included in the treatment process.

Credit Card Authorization: Dr. Davis will always hold appointment times for you in his schedule, and in return requests that you fill out this form. He will only charge your credit card in the following situations: (a) cancellation less than 48business hours in advance of your appointment, (b) no show for appointment, (c) additional services rendered agreed upon by you (i.e, phone sessions, report writing, etc.), and (d) lack of payment for appointments.