Forms

Below is a directory of the forms that I have new clients read and sign.  The information release form is not always needed — it’s provided so you can see what the form looks like if you’ve had a doctor or therapist in the past whom I should talk with.

I have forms below for out-of-pocket/out-of-network clients as well as insurance clients (currently accepting Hopkins EHP and USFHP, CareFirst BCBS, Magellan, Beacon Health / Value Options, Evergreen Coop, Cigna, and Aetna).  Medicaid/Medical Assistance/PAC clients have a different set of forms a bit further down the page.

Out-of-Pocket Clients and Commercial Insurance Clients

(Private Pay, Out-of-Network, Johns Hopkins EHP and USFHP, CareFirst BCBS, Magellan, Beacon Health / Value Options, Evergreen Coop, Cigna, and Aetna)

Please bring these with you or be prepared to fill them out at your first session.  We should have already spoken via email or phone and agreed to an appointment before you fill these out.

Demographics and Financial Information Credit Card Form
Background Questionnaire (Intake Form) Information Release Form
Individual Therapy Agreement  PHI Notification Election

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Maryland Medicaid Clients

I am able to accept most forms of Maryland Medicaid from the various MCOs (Managed Care Organizations) including Priority Partners, Amerigroup, Maryland Physicians Care, MedStar, Priority Partners, and United Healthcare (Medicaid only).

Please bring these completed forms with you or be prepared to complete all of them at your first session.  You may wish to arrange to arrive early to work on these in the waiting room prior to our first session (tell me you want to do this before coming early).  We should have already spoken via email or phone and agreed to an appointment before you fill these out.

 

Demographics and Financial Information Credit Card Form
Background Questionnaire (Intake Form) Information Release Form
Individual Therapy Agreement Advance Directive Form
PHI Notification Election Advance Directive Booklet
DHMH Substance Abuse Release Form

 

Hygeia Counseling Privacy Policy

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