NEW PATIENT FORMS
If you are a new patient, please complete the following forms: New Patient Form, Office Policy Form, Telemedicine Authorization Form and HIPAA Medical Privacy Notice. Each of these forms can be completed and signed electronically using Adobe. No later than two (2) days before your appointment please email the fully completed and signed forms together with a copy of the front and back of your insurance card to [email protected]. In addition, please provide the email address you would like Dr. Andersen to use to provide communications concerning your appointments and the instructions and link for telemedicine appointments.
- New Patient Form
- Office Policy Form
- Telemedicine Authorization Form
- HIPAA Medical Privacy Notice
- HIPAA Disclosure Authorization (Optional)
- HIPAA Notice of Privacy Practices (Review only)
If you would like Dr. Andersen to coordinate care with another provider (for example: your psychiatrist, primary care physician, etc.), complete this form to authorize the release of your personal health information.
Note: To download Adobe Acrobat Reader for free, click here.