Terms Regarding Forms
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 with any insurance 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 48 business 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.