CBH FORMS
CBH Forms
Welcome to CBH Forms where all the forms are available in one place for your convenience!
We know filling out forms can be a pain. We made it EASY and convenient just for YOU! Forms can be filled online directly (Submit Online) or using fillable pdf or print (Fillable PDF or Print) and fill out with a pen and return to us during your first appointment.
INTAKE
CONSENT FOR OUTPATIENT TREATMENT
OFFICIAL FINANCIAL POLICY AND BILLING AGREEMENT
AUTHORIZATION FOR DISCLOSURE OF INFORMATION
- INTAKE
- CONSENT FOR OUTPATIENT TREATMENT
- OFFICIAL FINANCIAL POLICY AND BILLING AGREEMENT
- AUTHORIZATION FOR DISCLOSURE OF INFORMATION
INTAKE Information
Marital Status
Please list children and ages
Emergency Contact
Insurance Information
CONSENT Information
FINANCIAL Information
Payment:
HIPAA Compliance Information
HIPAA Privacy Notice Acknowledgment “By signing below, I acknowledge that I have been informed that my personal health information is protected by the Health Insurance Portability and Accountability Act (HIPAA). I understand that my information will be kept confidential and only shared with authorized individuals or entities, as permitted or required by law. I have been provided with a copy of the organization’s HIPAA Privacy Notice, which outlines my rights and the ways in which my information may be used and disclosed. I consent to the use and sharing of my health information as described in the Privacy Notice.
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