Policy, Registration, and Release Forms
For your convenience we have provided the following forms for you to download. Some require Adobe Acrobat Reader software to read them, which is usually included in your browser. If you do not have Adobe Acrobat Reader software,please click here to install it.
Follow this checklist of action items to determine your Out-Of-Network insurance coverage: Out-Of-Network Treatment Checklist.
Please print the following forms, fill them out, and bring them with you on your first visit to one of our offices.
—-> IMPORTANT: Do not send confidential material in email, as it is not secure.<—-
|PatientRegistration – This form registers you with our records.
Notification of Privacy – Notice of policies and practices to protect your privacy.
Consent to Treatment – Allows Spectrum Behavioral Health to treat you.
Financial Agreement – Explains SBH’s payment policy so you understand and agree about payment for professional services.
Waiver Of Benefits – Needed if you wish to pay for services instead of going through your insurance plan.
Authorization for Assignment of Benefits – Allows SBH to submit charges to your insurance plan.
Medical Records Release/Transfer – Authorizes your clinician to release protected health information from your clinical record to the people you designate, and vice versa.