Forms and Handouts

HIPAA Privacy Release (send/receive records)

This allows us to coordinate care with therapists, teachers, family members, or primary care physicians. You can sign it electronically. Bonus if you have contact information, but whatever you have is great.

Insurance Updates Forms

This form allows you to sent us your insurance updates so the office can bill your insurance company, and you as accurately as possible.

Prescriber Intake Form (also used in ADHD)

Fill this out if you are seeing one of our prescribers at least 3 days before your appointment! Best to be at a laptop.

Request for ADHD Rating Scale

Your clinician may have asked you to submit a request for an ADHD rating scale to be sent to your email.

For outside clinicians/family

If you share a patient with us, you can securely get a message directly to the clinician. Of course we’ll need permission to confirm or deny we see this patient.

Controlled Substances Treatment Contract

Our agreement with all patients who are prescribed controlled substances.

Prior Authorization Request

Use this to request a prior authorization for medications if your pharmacy states you need one.

Clinic Policies

Clinic policies and our promises to you

Anxiety and Depression screening

Dr. Kumar will review these with your at your next appointment

Patient Complaint Form

Use this form to send in a patient complaint, which will be reviewed by the Practice Manager and Owner of the practice.

Credit Card Update (Secure)

Use this form to securely update your credit card information. 

Genetic Testing Request (for existing patients only)

Use this form to request a Genetic Testing Kit be sent to your home. (only existing patients)

Thank you!