Patient Forms

Forms For In-Person Patients

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Welcome to the DBHC Forms webpage. These are mainly for New Patients but look below for other forms that existing patients may need.

We have three options for you to complete the needed forms for your first visit. We also have other forms available for things like change of address, permission to share information, or to request a copy of your records.
The three options are:

1. Fill out the form at the office once you arrive. This takes about 30-minutes and will impact the amount of time Dr. Beverly will have to work with you as the total initial time for new patients in 90-minutes.
2. Download the forms and bring them with you to the New Patient Visit. This option saves the time waiting for you to complete the forms and then you must wait while Dr. Beverly reviews the forms with you.
3. Fill out the online forms and submit them at least 24-hours prior to your New Patient appointment. This option saves the most time as it allows Dr. Beverly to review your case in advance and no waiting to fill out the forms. You will also have the option to save a copy of the form to your computer in PDF format for your records.

 

Choose whichever option above fits your schedule and ability to use technology.

New Patient Forms

• New Patient Intake (choose one option below)
• Download the New Patient Intake Form
• Fill Out the Form Online (coming soon!)
• Concent to Treat & Acknowledge Receipt of Privacy Practices Forms (choose one option below)
• Download the Financial Agreement Form
• Sign the Concent to Treat Form Online (coming soon!)
• Sign the Acknowledge Receipt of Privacy Practices Form Online (coming soon!)
• Privacy Policy (FYI for HIPAA)
• Download the Privacy Policy Form, for your information only.

 

Other Forms (see * note below)

• Change Of Name, Address, email, and/or Phone for Current Patients ONLY.
• Download the Change Of Address Form
• Fill Out the Change Of Name, Address, email, and/or phone number Form Online. Click the Submit Button when Finished.

 

* Any forms that need to be made for other entities, like attorneys, will have the standard photocopy costs and time to copy charges applied and billed either to you or the entity requesting the copies depending on the circumstances. You are entitled to receive one personal copy for you at no charge. After the first copy standard charges for copies and time will be charged. Since the going rate changes please contact DBHC for these charges. Generally, they are paid by the attorneys as part of the settlement when applicable.

 

Aside from any forms that are filled out online, all patient records are kept in paper form at the DBHC office. There is a monitored alarm system in case of a break-in, so your records are secure from digital hackers. Once online forms are completed, they will be removed from the online system so you will need to keep your own copy if you want them.

 

Contact Us Today

Contact us today to learn more about our services and how we can support your holistic well-being.