Registration and Billing Forms (For new intakes: Please complete #1-4 and either #5 or #6 depending on your situation and submit them to your doctor before the first appointment)
- Patient Registration Sheet (contact information; please sign where indicated on page 2; HIPAA info is provided below and your doctor is licensed with the Medical Board of California – please see notice at the bottom of this page)
- Health History Questionnaire (for initial intake)
- Office Policy Statement for Dr. Sutherland (please review and sign)
- Payment by Credit Card Form (for monthly balances, co-payments, incidental charges, costs not covered by Aetna or MHN if we bill them)
- Financial Responsibility Agreement – Private Pay ( for those paying out-of-pocket for services) OR
- Financial Responsibility Agreement – Insurance (for billing Aetna, MHN only; CAPP does not bill other insurance companies)
- See Miscellaneous Forms below if you have Medicare
Please check out the Open Payments database notice at the bottom of this page.
Authorization for Release of Information Forms
Release of Information Authorization (allows your doctor to share information with specified person such as a relative or former, current or new provider if you wish)
Request for Transfer of Medical Records (allows your doctor to send your records to a specified person, usually another provider)
Health Information Privacy Practices (HIPAA) Information
Notice of Health Information Privacy Practices (FYI – to read about CAPP’s privacy policy)
CAPP Statement on Privacy (FYI – additional information)
Miscellaneous Forms
Medicare Private Contract (only if you are a Medicare patient and wish to pay privately as your doctor is opted-out of and does not bill Medicare)
Screening Tools
Adult ADHD Self-Report Scale – a free self-assessment tool (for those being evaluated for ADHD)
Patient Health Questionnaire (PHQ-9) – depression assessment tool; 2 versions: Adult version & Adolescent version (for those being evaluated for depression)
GAD-7 – quick screening tool for anxiety (for those being evaluated for anxiety)
Open Payment Database Notice
As required by law, you as a patient should be made aware that The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
NOTICE TO PATIENTS
Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov,
email: licensecheck@mbc.ca.gov,
or call (800) 633-2322.