Please locate and complete the forms you need. 

 

Consent for Use of the Telemedicine 


Click to Download Form
 

Medicare Private Contract 


Click to Download Form

 

Insurance and Financial Policies 


Click to Download Form

 

Receipt of Privacy Notice 


Click to Download Form

 

Suboxone Patient Forms 

For Suboxone patients only.  If you are a Suboxone patient please complete and print all pages of the form.  More information on Suboxone may be found at www.HereToHelpProgram.com or by calling 866-973-HERE(4373). 
Click to Download Form

 

Patient Demographics 

Please fill out all pages of this form if you are a new patient coming to see Dr Fitzgerald and bring it to your first appointment. Remember to BRING YOUR INSURANCE CARD even if you don't think you will be using it for your visits. 
Click to Download Form

 

HIPPA Recepit of Privacy Notice  

Please read, sign, date, and bring to your first visit with Southlake Psychiatry

Click to Download Form

 

HIPPA Notice of Privacy Practices (Please Read) 
 

HIPPA Authorization for Disclosure of Information 

Please fill this form out if you wish records to be copied for you, another professional or Institution. Please note that HIPPA guidelines allow up to 30 days for us to provide copies of records if your provider agrees with the request as outlined in the Privacy Practices above. Also, fill out this form if are a patient and would like your provider to have permission to discuss your treatment with someone. Please note Authorizations for Disclosure of Information are valid until revoked in writing at any time. 
Click to Download Form

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