Communication Consent Form (PI)

Availability updates are provided on our website.

Did someone refer you (please put name below), or are you making the request yourself?

First Name

Middle Initial

Last Name

Gender

Date of Birth

Month

Day

Year

*Complete Street Address

City

State

Zip

Email (double check, please)

Cell Phone

May we CALL you at this number?

Yes

May we TEXT you at this number?

Yes

SELECT YOUR PROVIDER (2 options):

INSURANCE/PAYMENT PREFERENCE: (We are not enrolled in government-issued medicaid)

BCBS ND or BCBS PPO

Please upload your insurance card below.

Sanford Health

Please upload your insurance card below.

Private Pay

*If using your insurance, please include a picture of the front side of your card.

* UPLOAD INSURANCE CARD PICTURE HERE * REQUIRED *

Add file

Please upload a file

NON-TRADITIONAL COMMUNICATION CONSENT:

We use HIPAA-compliant technology to reduce wait times, improve the intake process, and ensure that you have access to your provider when needed. We need your consent in order to move forward. Your provider will explain each service in detail.

I consent to HIPAA-compliant texting and email notifications for my appointments, provider communication, invoices, and receipts.

I consent to provide/allowing charges on my credit card for the balance due at the time of the appointment (self-pay clients only). If using insurance, I consent to charges for my co-payment, and co-insurance once my claim has been processed.

By sending this, I consent to the use of digital forms.

Watch your inbox/spam for our reply.

Your information will be encrypted.