Notice and Forms


	Forms, Notices, and Brochures indicates notice and forms required of new clients (All non new client forms are explained in our Notice of Privacy Practices which is available and listed below) Access Request Form Accounting Request Form Advanced Directives -- General Health Care & POLST (Provider Order of Life Sustaining Treatment) Advance Directive -- Psychiatric Amendment Request Form Authorization for Release of Info. Form Authorization Revocation Form Collateral Consent Form Confidential Communication Request Form Consent Form COVID-19 In Person Consent Form Credit/Debit Cards Informed Consent Email & Texting Consent General Information Form Identity Verification Form Explained Insurance Release Form Notice of Privacy Practices Notice of Privacy Practices Receipt Optum Wellness Assessment Forms Privacy Complaint Fact Sheet Privacy Complaint Form Restriction Request Form *Telepsychology & Telemental Health Consent Form
404 East 4500 South, Suite B22, Murray, Utah 84107-2776 801-268-1564 Email
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