Office Policies

Patient Release of Information Consent Form

Medical Release of Information Form

To request that medical information about you be sent to another physician, your employer or another entity, this form must be completed and signed. This allows Total Care Behavioral Services permission to release or obtain protected medical information on your behalf.

Fees for Special Information Requests

Our practice receives many requests to complete various patient forms such as insurance, disability, FMLA, and handicapped parking. Completion of these forms requires medical expertise and a review of medical record documentation. For this reason, a fee based on complexity and length of the forms will be collected prior to releasing the form; no forms will be completed prior to payment of fees.  It is the patient’s responsibility to complete their portion of the form and submit it to the requesting party.

Please refer to the fees indicated for applicable requests. If you mail the form to us, please make sure that you send payment with your request. No forms will be completed prior to payment of fees.

Fees for completion of forms will be determined at time of the visit; there is a minimum $75 fee.

Notice of Privacy Practices

Review the HIPAA Privacy Rules page for more information about the practice’s patient privacy practices.

Each patient must sign a Patient Consent Form which gives Total Care Behavioral Services permission to use protected healthcare information about you in order to carry out treatment, payment and general healthcare operations.

Total Care Behavioral Services Notice of Privacy Practices describes how your medical information may be used or disclosed. Please review this document carefully. You may obtain a paper copy of this Notice upon request.