NTX

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{{r.practiceName}}

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Provider Contact

{{provider.practiceName}} {{provider.title}} {{provider.streetAddress}} {{provider.city}} {{provider.state}} {{provider.practiceZIP}} {{provider.practicePhone}}

Special Instructions

Upcoming Appointments

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No Appointments

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Messages {{messageCount}}


{{m.posted \| date:'shortDate'}}	{{provider.practiceName}} {{provider.title}}
	{{m.message}}

Self Reporting

PHQ9

GAD7

PCL5

dsm5 DSM5 Done

[ PHQ9 New Score ]

[ GAD7 New Score ]

Past Medical History [Done]

Past Medical History [Please Fill In]

Allergies

Current Medications

Past Medications

Past Psychiatric History

Contact info

Dependent Please fill the School/Guardian Section

First Name

Last Name

Cell Phone

Home Phone

Office Phone

Select Preferred

Gender

Date Of Birth

Address

Address cont

City

State

Zip Code

Emergency Contact

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School and Guardians

Guardian 1

Relationship

Name

Address

Phone

Other

Guardian 2

Relationship

Name

Address

Phone

Other

School

School Contact

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Other Providers/Contacts

Please add all providers, and check box for those you wish to authorize your provider to contact. View Release of Information.

Authorization for {{provider.practiceName}} {{provider.title}} to Use or Disclose My Health Information

You may use or disclose all my health information (including mental health and substance abuse treatment records) maintained by {{provider.practiceName}} {{provider.title}} to [other provider] at my request, for the purpose of coordination or transfer of treatment. I also authorize [other provider] to release my health information (including mental health and substance abuse treatment records) to {{provider.practiceName}} {{provider.title}} for the purpose of coordination and transfer of treatment.This authorization ends when I end my treatment with {{provider.practiceName}}.

My Rights:

I understand that I do not have to sign this authorization in order to get health care benefits (treatment).
I understand I have a right to a copy of this authorization (available electronically on my patient portal).
I may revoke this authorization in writing. If I did, it would not affect any actions taken by {{provider.practiceName}} based upon this authorization. Once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.

Add Provider

{{p.fName}} {{p.name}} {{(p.type)?p.type:p.specialy}} I have read and agree to Release Of Information

Pharmacies

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Required Forms

I have read and agreed to {{f.formtitle}}	on {{f.dateSigned}}

Account

Recent Statements

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Credit Card {{ccStatus}}

Credit Card On File ending in {{p.CardNumber}}

Billing Address Same as Home

Balance: {{balance \| currency}}
{{t.dateAccrued \| date: 'shortDate'}}	{{t.CPTCode}} {{t.paymentType}} {{t.checkNumber}}	{{t.charge \| currency: '$'}}	{{t.duration}} mins at {{t.rate}} $/hour	{{t.comment}}

stripe

We texted your temporary password to the phone number on file. OK

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1 Provider

{{providers.length}} Providers

{{p.practiceName.substring(0,2)}}****

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Chart

{{patient.fName}} {{patient.lName}}

Guardian 1

Guardian 2

Recent Statements

Credit Card {{ccStatus}}

Billing Address Same as Home

Welcome to {{newreg.provname}}

{{newreg.provname}} is accepting new patients. To book an appointment please register below.

Chart

{{patient.fName}} {{patient.lName}}

Guardian 1

Guardian 2

Recent Statements

Credit Card {{ccStatus}}

Billing Address Same as Home

Welcome to {{newreg.provname}}

{{newreg.provname}} is accepting new patients. To book an appointment please register below.

Find your provider and click RESET