TelePsychiatry Associates

Personal Details

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Middle Name:

Last Name: *

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Valid Email: *

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Retype Password: *

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Responsible Party

Responsible Party *

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Relationship To Patient:

Insurance

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Primary insurance

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Emergency Contact

First Name: *

Last Name: *

Home Phone: *

Work Phone: *

Mobile Phone: *

Relationship To Patient: *

Authorization

The physicians and staff of TelePsychiatry Assocaites know that communicating with you about your healthcare is important. By completing this form, you give us permission to provide messages and/or discuss information about your healthcare with the individuals designated below.

Name:

Relation:

Phone Number:

Please do not discuss my medical information with anyone other than myself. I understand that checking this does not prevent my healthcare provider from disclosing my medical or billing information as may be otherwise allowed under state and federal privacy law. I understand that all patients registered with TelePsychiatry Associates, LLC, must agree upon registration to leaving and receiving messages via the HIPAA compliant, encrypted, website messaging service, our HIPAA compliant GSUITE service, their personal phone, voicemail, email, address(es) or texting contact numbers provided to TelePsychiatry Associates as well as any electronic means with which a patient has initiated contact with TelePsychiatry Associates. If you prefer NOT to be contacted by any of the means listed here, please give written notice to TelePsychiatry Associates within one week of registration or as soon as you decide that you want that chosen means of contact terminated. In addition, you understand that not all electronic means that can be used to contact TelePsychiatry Associates, such as chat boxes, via independent websites, third party email systems, etc may not be HIPAA compliant and subject to HIPAA regulations.

I understand that I may cancel or change this authorization at any time by providing a written request to TelePsychiatry Associates

Electronic Signature of patient, parent, or guardian:

Date:

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