Forms

Prior to your first appointment, please read the HIPAA form notice (no need to print this page).

Please print, fill out, and sign the following documents:

  • ¬†HIPAA acknowledgement
  • Intake form
  • Contract
  • Assignment of Benefits Form (if using insurance)

The Release of Information Form is only needed when a client desires that we talk or exchange paperwork with another provider or friend/family member. You can scan and email them to intake@bloomandbetherapy.com or fax to 833-409-2179 ahead of your appointment time or bring them with you if needed. Thank you!

HIPAA Form

This is a statement regarding how we utilize your PHI (private health information).

HIPAA Privacy Notice Acknowledgement 2022

Please sign this to acknowledge receipt of the HIPAA form above.

Pediatric Intake Form (Updated – 2021)

This is a case history form so we can have a better understanding of how to work with your child.

Private Client Contract (Updated -2022)

This has information pertaining to fees, scheduling, and other impohttps://www.bloomspeechandlanguage.com/wp-content/uploads/2021/11/private-client-contract-UPDATED-111821.pdfrtant business information.

Release of Information

This needs to be filled out if you need to give permission for us to reach out to another provider or if another provider is requesting information from us. This is also necessary if you would like us to be able to provide health information to another friend/family member.

Insurance Verification Form

Clients may find this helpful when calling to ask about out of network coverage for superbills.

Assignment of Benefits Form

This form gives Bloom & Be permission to bill insurance on your behalf.

Please ask for our prompt pay rate sheet.