Amy Lane APRN

CONTACT:

(860)823-0245 or

amylaneaprnllc@gmail.com

Copyright
© 2013 | Amy Lane APRN

Telehealth Consent Form

Release of Information

RELEASE OF INFORMATION FORM:

Please include name and numbers of individuals that information is to be released to on the form before submitting

Financial Agreement

Responsibilities of Provider

Please print and bring the following FORMS with you to your first Appointment:

Consent To Treat and HIPPA Receipt

Please read the following:

NEW CLIENTS:

Please fill out the forms BELOW and return them to the office via email attachment, FAX, ALONG WITH YOUR INSURANCE CARD. Photos cannot be downloaded in the system.

Patient Rights and Responsibilities

Client Intake Form

Client Forms for Download:

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