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Print out the Provided Forms for Our Behavioral Health Center in Park Ridge, IL

For your convenience, you can download and complete our practice forms before your visit. If you have the new Adobe Reader DC, you can “Fill and Sign” on line and then print them. The forms are necessary and will be provided in the waiting room if not completed prior to your visit. We do not provide for the electronic transmission of the forms, as we cannot assure privacy over the internet. The five forms include the following:

1. Registration
2. Insurance Release
3. Provider-Patient Agreement
4. Payment Authorization
5. Child/Adolescent or Adult History

We also ask that you complete the Adult History Form for adults seeking consultation, or the Child and Adolescent History Form for kids under age 18, as they provide us with important information and will allow us to focus more on your concerns during your meeting time. The Notice of Disclosure is available at our office or is available here for your records. We will review and further explain the forms during your visit. We understand that the information appears lengthy; however, it will allow us to spend more time talking with you during your visit and will help expedite accurate and complete claims processing meeting all HIPAA requirements.

Please bring the forms with you on the day of your visit, or you may fax them to our dedicated and private fax line: (847) 823-4456. This will save you time when you visit with us. Thank you. We make every effort to maintain all of our staff on a comprehensive list of insurance panels listed below. We cannot always guarantee accuracy, however, due to constant changes in the industry. We ask that you verify your benefits and that we are listed on your plan through your insurance company.

We will also require a picture ID (for your security) and a copy of your insurance card when you arrive.

1) Registration

2) Insurance Release

3) Provider-Patient Agreement

4) Payment Authorization

5) Child and Adolescent History
(Includes 18-year-olds still in high school)

6) Adult History

7.) Illinois Notice of Disclosure

8) Written Consent for Disclosure of Records & Communications

9) Informed Consent For Telepsychology Services

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