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HIPPA AND PATIENT SERVICE AGREEMENT FORMS (These must be signed)
HIPPA Forms (available to all)
CPANCF Service Agreement Form
 
RELEASE FORMS (Fill these out if you wish information to go out or come to us)
USE THIS FORM TO RELEASE RECORDS FROM SOMEONE ELSE TO US
USE THIS FORM TO HAVE RECORDS RELEASED FROM US TO SOMEONE ELSE
 
HISTORY FORMS  (Please complete the appropriate history form prior to your appointment - call office if you forgot password)
Child History Form Packet (password required) HIPAA form & Service Agreement
Adult History Form Packet (password required)
Adolescent History Form Packet (password required) parent form, HIPAA form & Service Agreement
 
CITY OF GAINESVILLE EAP FORMS
Service Agreement
Intake Form
HIPAA Form
 
Consent to Psychological or Neuropsychological Independent Medical Evaluation "IME"
 
FILING YOUR OWN INSURANCE FOR OUT OF NETWORK BENEFITS
Instructions for filing your own insurance - sample Superbill
BCBS patients should complete this form with the superbill and submit the form to the address indicated.
Florida State EmployeeBCBS should use this form with the superbill 
Federal Bluce Cross Blue Shield out of network Claim Form (file with superbill) (PDF)
Federal BCBS out of network claim form (en Espanol) (PDF) 
 
CONSULT FORMS (If you are a physician or other referall source)
Neuropsychology Services Consult Form  (Microsoft Word)
Neuropsychology Services Consult Form (PDF)
 
RESOURCES
Memory Help Websites, Reading, Computer Programs and Games - List (PDF)
City of Gainesville EAP Brochure1/28/2010 (PDF)
Download a Brochure of our General Services (PDF)
Alachua and Marion County Alzheimers Association Meeting Schedule
 

DOCUMENT FOR A RARE BREED OF FPA MEMBER

 

DOWNLOAD OUR BROCHURES (all rights reserved, you may copy as long as no modifications are made)



 

 

 
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Gainesville Office: 2121 NW 40th Terr. Ste B. Gainesville, FL 32605  -   Phone: (352) 336-2888  -   Fax: (352) 371-1730
Ocala Office: 108 N. Magnolia, Suite 309, Ocala, FL 33475  -   Phone: (352) 629-1100   Email Us  Terms of Service  Privacy Policy