Patient Forms

INDIVIDUAL PATIENT FORMS

Release of Information

Patient History

Vanderbilt Assessment Forms

Parent Initial Assessment

Parent follow-up

Teacher Initial Assessment

Teacher follow-up

Screen for Child Anxiety Related Disorders

To be completed by Child

To be completed by Parent

INSURANCE BILLING

We are not in network with any insurance companies, and payment is due in full at the time of service.  We provide a Superbill (a detailed receipt) that can be submitted to insurance for reimbursement and are happy to provide assistance with that process if needed.  Here are some links to reimbursement forms/procedures for some of the more common insurance plans:

Aetna: Health Reimbursement Claim Form

Cigna: Reimbursement Medical Claim Form

Providence: Member Forms

Regence: Direct Member Reimbursement Form

United: Medical Claim Form

MODA: Claim Forms

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