Practice Forms
New Patient Paperwork Please complete these forms and bring them with you to your first appointment. Please arrive 15-20 minutes prior to your appointment time with your photo ID and a copy of your insurance card. | |
Authorization to Release Health Information (ROI) Please complete this form if you would like CBHA to disclose your personal health information with anyone other than yourself or to obtain records from your previous providers. | |
TelePsych Informed Consent If you are a client who is interested in TelePsych services, please complete this form and fax it (860) 823-1170. | |
General Office Policy Attached you will find the most up-to-date office policies regarding; canceling or rescheduling of appointments, NO SHOW/LATE CANCELLATION policy, medication refills, paperwork/forms or medical records requests. | |
Client Insurance Form If you have new or updated insurance information, please complete this form and bring it to your next appointment with a copy of your insurance card. Also contact billing at ext. 252 to ensure proper billing of your claims. | |
Financial Policy Attached you will find the most up-to-date financial policies regarding; acceptable payment methods, service/administrative fees, No Show/Late Cancellation fees and Collection fees. | |
Client Intake Form If you are seeking to become a new client of CBHA please complete this form and fax it to (860) 823-1170, drop if off at any CBHA location or email it to intake@cbhapc.com. A member of the Intake Department will contact you upon receipt. | |
Intake Assessment Form If you are a provider and wish to refer your client for out-pt treatment from a higher level of care, please complete this form and fax it to (860) 823-1170. A member of the Intake Department will contact you upon receipt. | |
TMS Referral Form If you are a provider and wish to refer your client for Transcranial Magnetic Stimulation, please complete this form and fax it to (860) 823-1170 or email intake@cbhapc.com The TMS Coordinator will contact you upon receipt. | |
Spravato Referral Form If you are a provider and wish to refer your client for Spravato, please complete this form and fax it to (860) 823-1170 or email intake@cbhapc.com The Spravato Coordinator will contact you upon receipt. | |
Specialized Services Intake Assessment Form If you are a provider and wish to refer your client for out-pt substance abuse treatment from a higher level of care, please complete this form and fax it to (860) 823-1170. A member of the Intake Department will contact you upon receipt. | |
Therapy Verification Form For clients who are required to seek therapy and see a provider outside of CBHA, this form is required to show proof of on-going treatment. | |
Job Application Please complete a Job Application and forward your resume, cover letter and three references to 860-823-1170. |