Thank you for your ongoing interest in our work. To start the scheduling process, please download, complete and sign the following forms so we can start to build your chart. Complete and sign a Medical Records Release (MRR) for every physician you have consulted in the last 18 months. We will contact them to request your records.
To expedite your scheduling, please return all documents by email (firstname.lastname@example.org) or fax (1-352-336-9980) within 48-72 hours.
Optional: You may wish to review these additional forms, which will be required after you schedule.
- HIPAA Consent (Clear Passage Therapies Inc.) Depending on the location you choose to attend, we may send you an additional HIPAA consent form required for that location.