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https://diligenceintegratedcare.com

Patient’s Forms

Patient Registration Form Click to Fill the Form Credit_Debit Card Collection Click to Fill the Form CONSENT FOR TREATMENT Click to Fill the Form Authorization to Release Medical Information Click to Fill the

Required Form

Go to the Forms Page by Filling Required Information…! Name* Email*

STANDARD PSYCH FORM INTAKE ZD

Go to Back Please fill this form to send it to your Physician Standard Zych Form Intake ZD Patient Registration Form Patient Information First NameMiddle NameLast NameSexMarital StatusDate of Birth (Age)Social Security NumberPatient’s

Patient-Provider Policy Agreement

Go to Back Please fill this form to send it to your Physician Patient-Provider Policy Agreement Patient-Provider Policy Agreement Appointment PolicyAppointments may be scheduled by phone or online. If you are unable to

TREATMENT CONSENT FORM

Go to Back Please fill this form to send it to your Physician TREATMENT CONSENT FORM TREATMENT CONSENT I/we are providing consent forto receive treatment for (medical problem)with the following treatment(s): I/we understand

OFFICIAL POLICIES & GENERAL INFORMATION

Go to Back Please fill this form to send it to your Physician OFFICE POLICIES AND GENERAL INFORMATION Office Policies & General Information Office Policies and General Information Agreement to Provide Mental Services

CONSENT FOR TREATMENT

Go to Back Please fill this form to send it to your Physician CONSENT FOR TREATMENT CONSENT FOR TREATMENT I authorize and request that my provider at Diligence Care Plus carry out psychological

FEE AGREEMENT AS OF 08-21-2023

Go to Back Please fill this form to send it to your Physician FEE AGREEMENT AS OF 08-21-2023 Fee Agreement We know that unexpected medical costs are one of the most common sources

HIPPA & PRIVACY NOTICE

Go to Back Please fill this form to send it to your Physician HIPAA and Privacy Practices Notice HIPAA and Privacy Practices Notice This Notice describes how medical information about you may be

Credit Card Collection

Go to Back Please fill this form to send it to your Physician Credit/Debit Card Payment Consent Form Credit/Debit Card Payment Consent Form Financially Responsible Party:Middle NameLast NameName on Card if different: I