Complete Your Required Forms with Ease
To begin your journey with University Place TMS Clinic and General Psychiatry, please review, complete, and submit the required forms listed below. These forms are essential to ensure you receive the highest quality care and to protect your privacy and rights.
What are your signing options?
What service are you looking for?
1. Online Signature
For convenience, you can sign your forms electronically through our DocuSign link, which will allow you to review and sign securely online.
2. Download and Email
If you prefer, you may download each form, sign it by hand, and send the completed forms to us at [email protected].
Forms to Complete and Submit
This form authorizes us to share your health information for treatment, payment, and health care operations as needed. Signing confirms your consent to these uses and disclosures. Click Here To Download This Form
If prescribed a controlled substance, this contract outlines important guidelines to ensure safe, responsible use. Signing confirms your agreement to these terms. Click Here To Download This Form
At University Place TMS Clinic & General Psychiatry, we are committed to protecting the privacy and security of your health information. This notice provides an overview of how your health information will be used and disclosed specifically regarding Transcranial Magnetic Stimulation (TMS) Therapy, as well as your rights under the Health Insurance Portability and Accountability Act (HIPAA). Click Here To Download This Form
This document includes important information about our services, policies, and your rights as a patient. Signing confirms that you understand and agree to our practices and policies. Click Here To Download This Form
This document outlines your rights under the No Surprises Act, explaining protections against unexpected medical bills. By signing, you acknowledge you’ve read and understood these protections. Click Here To Download This Form
This form provides detailed information about TMS (Transcranial Magnetic Stimulation) therapy, including its benefits, process, and potential risks. By signing, you confirm your understanding and consent to this treatment. Click Here To Download This Form
Forms to Complete and Submit
This form authorizes us to share your health information for treatment, payment, and health care operations as needed. Signing confirms your consent to these uses and disclosures. Click Here To Download This Form
If prescribed a controlled substance, this contract outlines important guidelines to ensure safe, responsible use. Signing confirms your agreement to these terms. Click Here To Download This Form
This document outlines how your personal health information (PHI) is used and protected under the Health Insurance Portability and Accountability Act (HIPAA). It explains your rights, including:
- Accessing your health records.
- Requesting amendments to your information.
- Limiting the disclosure of your information for specific purposes.
It also describes situations where we may need to disclose your information without your authorization, such as public health emergencies or legal obligations. By signing this form, you acknowledge that you’ve been informed about how your health information is managed and safeguarded. Click Here To Download This Form
This document provides a detailed overview of our professional services, policies, and your rights as a client. It includes:
- The qualifications and approach of your provider.
- The types of services we offer, including assessments, medication management, and therapy.
- Office policies, including our cancellation policy, telehealth practices, and payment procedures.
- Your rights regarding confidentiality, privacy, and termination of care.
By signing this statement, you confirm that you’ve read and agree to abide by these policies while receiving care at our clinic. Click Here To Download This Form
This document explains your protections under the No Surprises Act, which safeguards you from unexpected medical bills in specific scenarios, such as:
- Receiving emergency care from an out-of-network provider.
- Receiving treatment at an in-network facility but being billed by out-of-network specialists.
It also clarifies your right to:
- Pay only in-network cost-sharing amounts for certain out-of-network services.
- Avoid being balance billed for emergency services.
By signing this form, you acknowledge that you understand your rights and protections against surprise medical bills. Click Here To Download This Form
Submitting Your Signed Forms
For DocuSign Users
Once you complete the forms through DocuSign, they will be sent directly to our office, and no further action is required on your part.
For Downloaded Forms
After signing, please email the completed forms to us at [email protected]. Make sure each document is clearly signed and dated.
