PLEASE CLICK ON THE ICON FOR EACH OF FORMS 1, 2, 3, and 4.
( If you are covered by Medicare you must also complete Form #5.)
Click on the link to access each form. Save the document to your desktop. Fill it out, save it, and send it to me via my secure email.
PLEASE SEND THE COMPLETED FORMS THROUGH MY SECURE EMAIL -- DrBennaSherman@mdofficemail.com -- BEFORE YOUR INITIAL APPOINTMENT.
I look forward to getting to know you.
1. PERSONAL INFORMATION
2. PRACTICE POLICIES AND FEE AGREEMENT
3. INFORMED CONSENT TO PSYCHOTHERAPY
Form # 5 is only if you are covered by Medicare:
I am "Opted Out", which means that you cannot submit claims to Medicare for reimbursement for my services.
Medicare requires that you sign the following form agreeing to that.
5. PRIVATE MEDICARE CONTRACT
Form #6 is only if you wish or need to give consent for me to communicate with other providers
(for example, a psychiatrist, another psychologist, your physician)
6. RELEASE OF INFORMATION FORM
Form #7 is only if you require my participation in a legal proceeding
7. FEES AND POLICIES FOR LEGAL PROCEEDINGS