Release of Information Form
Please complete this form to:
You can fill out and submit our Release of Information Form online here .
Initial Evaluation / New Patient Appointment Packet
You can fill out and submit our New Patient Packet online . Please email [email protected] to request a new patient packet.
Please complete this packet prior to your scheduled initial evaluation. This is a somewhat lengthy packet requesting detailed information about past medical history and medications; we recommend completing these forms prior to the date of your appointment rather than in our office. Please do not fill out this packet unless you have scheduled your new patient appointment or have been requested to fill the packet out by our office.
This packet contains an Acknowledgment of Receipt of Notification of Privacy Practices.
Click here for a copy of our HIPAA Privacy Practices.
Please complete this form to:
- Allow Suzanne to speak with another person about your care.
- Have your records retrieved from or forwarded to another provider.
- Have your records forwarded to you, an attorney, or another family member (fee applies.)
You can fill out and submit our Release of Information Form online here .
Initial Evaluation / New Patient Appointment Packet
You can fill out and submit our New Patient Packet online . Please email [email protected] to request a new patient packet.
Please complete this packet prior to your scheduled initial evaluation. This is a somewhat lengthy packet requesting detailed information about past medical history and medications; we recommend completing these forms prior to the date of your appointment rather than in our office. Please do not fill out this packet unless you have scheduled your new patient appointment or have been requested to fill the packet out by our office.
This packet contains an Acknowledgment of Receipt of Notification of Privacy Practices.
Click here for a copy of our HIPAA Privacy Practices.
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Contact Us:
1101 S. Capital of Texas Highway Building A, Suite 200 Austin, TX 78746 [email protected] Office: (512) 617-6746 ext. 0 Telephone Hours: Monday - Thursday 10:00am to 5:00pm, Friday 9:00am to 2:00pm. Fax: (512) 387-8824 |
© Suzanne H. Grantham, PMHNP, PLLC 2017 |