Prior to your first appointment, please print out and complete the following forms and bring them with you to your first appointment:

• Client Information Form
• Treatment Consent Form
• Acknowledgement of Receipt of Notice of Privacy Practices

Also, please review the HIPAA Notice of Privacy Practices; printing of this form is for your records only.

If you have a psychiatrist or anyone else with whom you would like Dr. Novak to speak with, please complete the Release of Information Form and bring that as well.

INSURANCE:

If you are using insurance, you also need to sign a Release of Information for your insurance company. Please print the form that matches your insurance provider:

• Anthem Blue Cross Release of Information
• Blue Cross Blue Shield Release of Information
• Blue Shield of California Release of Information
• Cigna Release of Information
• Magellan Release of Information
• Medicare Release of Information

Discount Eligibility:

If you would like to leave a credit card on file to allow Dr. Novak to bill for missed appointments and to qualify to receive the discounted rate of $130.00 per session, please complete the Credit Card Authorization and bring that with you, too.