Download Forms

The following forms can also be downloaded for convenience.

Disclosure/Consent to Treatment (.pdf) / Notification Y Acuerdo del Paciente (.pdf) This form explains mutual expectations in treatment. It is to be read and signed before a patient’s first appointment.

Health History (.pdf) / Historial de Salud del Paciente (.pdf) This form conveys background data to your provider.

Notification Release / Recordatorios de Citas (.pdf) This form gives the office permission to provide clinical information to your primary care physician and to provide automated appointment reminder notification.

Release for requesting information TO SBBH (.pdf) This release of information form is used when a patient wishes to have SBBH request information from another provider of health care or behavioral health care; SBBH staff or your provider can advise you if it would be beneficial for you to authorize such release of information.

Release for releasing information FROM SBBH (.pdf) This release of information form is used when a patient wishes to have SBBH give information to another provider of health care or behavioral health care; SBBH staff or your provider can advise you if it would be beneficial for you to authorize such release of information.

Third Party Credit Card Authorization (.pdf) This form authorizes a credit card charge to guarantee payment for the exceptional situation in which a third party is making an appointment for a patient.

Assumption of Financial Responsibility (.pdf) / Asuncin de Responsabilidad Financiera (.pdf)This form allows patients to be seen without assurance of insurance coverage and benefits by their assuming financial responsibility for charges not covered by insurance.

Get Adobe Reader Adobe Acrobat Reader Gratis en Español