DW SIEVERT, M.D. INC.
DW SIEVERT, M.D. INC.

Forms

Authorization to Obtain Protected Health Information (PHI)
This form is required to be on file in our office should you choose to allow our office to speak with someone about you, your appointments or to release records on your behalf.
Authorization to Release PHI.pdf
Adobe Acrobat document [227.7 KB]
Authorization for Release of Records
This form is required to be on file in our office should you choose to allow our office to speak with someone about you, your appointments or to release records on your behalf.
Authorization_for_Release_of_Health_Info[...]
Adobe Acrobat document [67.5 KB]
Patient Access to PHI
This form is required to be on file in our office should you choose to allow our office to speak with someone about you, your appointments or to release records on your behalf.
Patient_Access_Request_Form_2.0.pdf
Adobe Acrobat document [106.9 KB]

New Patient Forms

New patients will need to fill out several forms before therapy can begin. To make the process as smooth and efficient as possible, we provide the most important documents as downloads right here on our website.

 

Contact your insurance company to open your case for pre-authorization for treatment and confirm mental health benefits before your first appointment:

 

1. Call your insurance company and get a prior authorization for “Outpatient Mental Health” services.

2. Ask for the “Insurance Claim Mailing Address” to submit your mental health claims.

3. We will need A CLEAR copy of the FRONT and BACK of all your insurance card(s) 7 days prior to your appointment.

NEW PATIENT PACKET
Return completed documents to our practice either in person, by fax or as a scanned PDF file via e-mail 24 hours before time of appointment.
NEW PATIENT PACKET 05-01-17.pdf
Adobe Acrobat document [248.0 KB]
Child NEW PATIENT PACKET
Complete this packet for children 12 and under. Return completed documents to our practice either in person, by fax or as a scanned PDF file via e-mail.
Child NEW PATIENT PACKET.pdf
Adobe Acrobat document [2.4 MB]
Suboxone NEW PATIENT PACKET
Treatment with Suboxone is cash only. Our practice does not bill insurance for Suboxone treatment.
Suboxone is a leading medication alternative in the treatment of opioid addiction. It became FDA-approved and available to the public in 2002 as a result of the Drug Addiction Treatment Act (DATA 2000). DATA 2000 allowed qualified physicians to prescribe buprenorphine (the active ingredient in Suboxone) to individuals suffering with chronic opioid addiction.
SUBOXONE NEW PATIENT PACKET.pdf
Adobe Acrobat document [1.1 MB]

Note: You will need Adobe(r) Reader(r) to view PDF files. If you do not have it, you can download it for free.

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