Clients who are 18 or older need to sign our intake forms to continue services at Catalpa Health. The necessary documents are below.
A few things:
- Please do not have your parents sign any of the forms. If they are obtaining legal guardianship for you after your 18th birthday, we have a different process. Those court documents can be submitted to us via fax to our privacy department at 920-882-0857.
- If you are still 17, please wait to sign the documents until your 18th birthday. They will be invalid if they are signed/dated prior to your birthday.
- Please reach out to us if you have any questions about this process or need help with the forms. Our call center hours are Monday – Friday, 8:00-4:30 and out phone number is 920-750-7000.
- As a legal adult, we will not be able to communicate with your parents unless you sign a release of information for them. They will not be able to help schedule appointments, request medication refills, or anything else without your consent. At this time we do not have an electronic signature option for this. You can print one here, otherwise we can mail it to you or you can stop by our clinic.
1) Review these 3 forms:
2) Sign these 3 forms:
- Click here to sign the Financial Agreement By signing this document you allow Catalpa Health to bill your insurance company for services rendered, and agree that you are financially responsible for any balance not covered by your insurance benefits.
- Click here to sign the Notice of Privacy Practices By signing this document you acknowledge that Catalpa Health has offered you a copy of the privacy practices (above) and that Catalpa follows HIPAA laws and will protect your healthcare information.
- Click here to sign the Informed Consent For Treatment By signing this document you are allowing Catalpa Health to provide treatment to you.