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/Patient Forms
Patient Forms2018-07-26T17:24:43+00:00

Patient Forms

The links below will open up as PDF documents that you can fill out once you download them to your computer.  Please print them out and bring them with you to your appointment, along with your insurance card.​

  1. Pondworks Patient Contact Information Form (signature required)
  2. Pondworks Practice Policies (signature required)
  3. Pondworks Acknowledgement of Privacy Practices (signature required)
  4. My Medicine Record (required)
  5. Medical Review of Systems (required)
  6. Pondworks Privacy Practices (for your information only; no signature required)
  7. Pondworks Patient Portal Agreement (signature required)
  8. Directions to Pondworks (print out)

​If you will be requesting medical records from another provider, OR giving permission for Pondworks to share confidential information (medical and/or billing) with someone, please complete the form below.  PLEASE ASK US if you are confused!!​

​The following forms are for you, to help with understanding your behavioral health insurance coverage:​

Pondworks – Insurance Terminology

​Pondworks – Behavioral Health Insurance Worksheet

​Pondworks – How to File an Out of Network Claim