Required Telemedicine/Telehealth Forms: Printable
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Pathways Clinic Telehealth Patient Printable Forms: 1. Demographic Form - Required for all Adult patients 2. Demographic Form - All Adolescent (13 year old and above) 3. Insurance & Financial Form - Required for all patients. 4. Credit Card Authorization Form - Required for all patients. 5. MH Informed Consent - Required for all patients. 6. Acknowledgement of Privacy Act - Required for all patients. 7. Telemedicine/Telehealth Informed Consent |
Mid-Valley Clinic Telehealth Patient Printable Forms: 1. Demographic Form - Required for all Adult patients 2. Demographic Form - All Adolescent (13 year old and above) 3. Insurance & Financial Form - Required for all patients. 4. Credit Card Authorization Form - Required for all patients. 5. MH Informed Consent - Required for all patients. 6. Acknowledgement of Privacy Act - Required for all patients. 7. Telehealth Informed Consent: Mid-Valley Clinic. |
OTHER Forms:
1. Release of Information Form - Optional; Complete if you would like us to communicate with anyone about your care.
2. Audio/Video Consent Form - Play Therapy only (Required for 6 to 12 year old)
1. Release of Information Form - Optional; Complete if you would like us to communicate with anyone about your care.
2. Audio/Video Consent Form - Play Therapy only (Required for 6 to 12 year old)
We cannot process your intake paperwork until we received all of the required forms and a copy of your insurance card and picture ID.
Please fax all the required forms and a copy of your photo ID and insurance card to (360) 846-1722 in Longview. Please do not email insurance cards or other confidential information as email is not a secure method of transmission. Once we have all forms and have verified your insurance coverage, we will call you to schedule an initial assessment.
Notice: Due to Washington health care laws, the ROI form should be completed by clients age 13 and up if a parent or other party will need to communicate with us about scheduling or other information.
Please fax all the required forms and a copy of your photo ID and insurance card to (360) 846-1722 in Longview. Please do not email insurance cards or other confidential information as email is not a secure method of transmission. Once we have all forms and have verified your insurance coverage, we will call you to schedule an initial assessment.
Notice: Due to Washington health care laws, the ROI form should be completed by clients age 13 and up if a parent or other party will need to communicate with us about scheduling or other information.
