Useful Forms

The following admission forms may be viewed and downloaded for your convenience by clicking on the blue box corresponding to the form you wish to view.  If you are able to download the forms, please complete them and bring them to your first appointment.  Please be certain that you sign the forms that require a signature.  If you do not have the capability to download these forms, they may be completed at the office.


Health Insurance Portability and Accountability Act (HIPPA): Notice of my psychology office’s policies and practices to protect the privacy of your health information.  This notice describes how psychological and medical information about you may be used and disclosed, and how you can get access to this information.  Please review prior to admission.

Confidentiality Statement:  This document is a written authorization form that meets certain legal requirements imposed by the Health Insurance Portability and Accountability Act (HIPPA). Please review and sign, prior to admission.

Informed Consent:  This document contains important information about my professional services and business policies.  Please review and sign, prior to admission.

Insurance Authorization:  This document is a written authorization form to use and disclose protected health Information (PHI) to your insurance company.  Please review and sign, prior to admission.

Fees and Payment Policy:  Please review and sign, prior to admission.


To review and download the forms, please click on the button that corresponds to the form you wish to view.












  


 










The most common way people give up their power is by thinking they don't have any.

                                      -Alice Walker


Contact Me

Ellen N. Emerson, Ph.D.
112 North College Street
Statesboro, Georgia 30458
Phone: (912) 764-3595



Ellen N. Emerson, Ph.D.