New Patient Forms:

The following handouts are for your review. Please read these BEFORE completing the New Patient Forms.

1. HIPAA Notice of Privacy Practices (.PDF)

2. Patient Handout(.PDF)

3. Welcome Letter(.PDF)

4. Communicable Disease Brochure(.PDF)

5. Advanced Directives Brochure(.PDF)

6. Know Your Rights Brochure(.PDF)

7. Medicaid Fair Hearing Brochure(.PDF)

 

By completing the following New Patient Forms, you are agreeing that you have read and understand the New Patient Handouts listed above.
IMPORTANT: All of the following forms must be completed in their entirety and emailed to MedicalRecords@Recoverypathwaysllc.com with your name and appointment date in the Subject line. Missing information or incomplete forms could result in your appointment being rescheduled. Alternatively, you may fax these forms to 989-391-9596, or 989-494-0405 if you are scheduled in Corunna.
If you have questions on any of these forms, please contact the office.

 

1. Patient Demographics(.PDF)

2. Informed Consent(.PDF)

3. Substance Use Disorder Treatment Agreement(.PDF)

4. Drug Testing and Pharmacy Consents(.PDF)

5. Medicaid/Healthy MI Plan Notice(.PDF)

6. Biopsychosocial History Form(.PDF)

7. DAST/Depression/Anxiety Screening Tools(.PDF)

8. Sucide/MAST Screening Tools(.PDF)

9. FASD/Communicable Disease Screening Tools(.PDF)

10. Nutrition Risk Assessment Screening Tool(.PDF)

11. Notice of Privacy Practices(.PDF)

12. Limited Authorization to Exchange Information with your Primary Care Provider(.PDF)

13. ACE Questionnaire(.PDF)

14. Opioid Risk Tool(.PDF)

Reminder - once complete, email all of these forms to MedicalRecords@Recoverypathwaysllc.com with your name and appointment date in the Subject line, or fax to 989-391-9596 or 989-494-0405 if a Corunna patient.

 

 

Consent to Release Protected Health Information: 

Limited Patient Authorization to Disclose/Obtain Protected Health Information:( .PDF ) print Copy

Limited Patient Authorization to Disclose/Obtain Protected Health Information:( .PDF ) Online Fillable

Sliding Fee Scale:

Application_for_Sliding_Fee_Discount_Program:(.pdf)

To apply for our sliding fee scale, please fill out this form and turn it into the office with your proof of income. You can send it to our email MedicalRecords@Recoverypathwaysllc.com or fax to 989-391-9596, or mail to 863 N. Pine Road Suite A Essexville, MI 48732.

If you do not include proof of income, the application will not be processed. If you have any questions, please contact the office at 989-928-3566.