A Child & Family Psychiatry
Forms
Online forms are completed through your browser and submitted to the appropriate ACFP Clinic staff.
PDF documents are downloaded to your device. Once completed the form can be returned to us by US mail, email, or in person.
Patients Forms
PDF Forms:
Patient Forms packet
Click here to download the three Patient Forms listed below in one .zip file
Form 1 – Please Read
Agreement and Privacy Notice
Client Policies and Procedures Agreement and Consent to Treatment / Telemedicine / Teletherapy Agreement and Consent to Treatment / HIPAA Notice of Privacy Practices
Form 2 – Please Sign
Office Policies, HIPAA, Consent for Services, Telehealth Agreement, Coordination
Form 3 – ROI
Release of Information Form
Records Release Authorization
Current Patients
Insurance
We accept Insurance from the following companies:
Aetna
Cigna
Optum/UHC
BCBS/Anthem
Medical Mutual
Tricare
For billing and insurance questions please send an email to
sandy@acfpclinic.com
Feedback
How are we doing?
Use this form to let us know:
Patient Feedback