INFORMED CONSENT CHECKLIST FOR TELEPSYCHOLOGICAL SERVICES

Please print the Consent form by clicking on the following link, sign it, and return to our office via fax at (866) 341-1114 or email at susan@drgifford.com..

Printable Telepsychological Consent Form
    Telepsychological Consent Form PDF (to Print and complete)

Insurance Only

To view or print a form that will help you discuss your insurance benefits with your insurance company, click on the following link. Please bring this completed form to your first appointment.

Printable Insurance Form
    Insurance Information PDF (to Print and complete)

Notice of Privacy Practices
    Notice of Privacy Practices

Patient Registration

To sign up online as a patient, please fill out the following forms, in order.
To insure the security of your data, you will only be able to review your input on these forms while your session is active; usually sessions expire after 20 minutes of internet inactivity. You can always press Submit on a form to save it, and thus renew your session timeout period, even if you haven't completed the form. Upon submission, you will be returned to this page, and you can click on the form you left incomplete to continue entering information.

Online Forms to Complete (Please Complete in order)
    Patient Information Sheet
    Patient Intake Sheet
    Patient Medical History
    Insurance Information
    Acknowledgement of Receipt of Privacy Notice

View or Print our Authorization for Disclosure Form

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