Patient Forms
Initial Patient Forms
New Patient Forms:
The links below will open up as PDF documents that you can fill out once you download them to your computer. Please print the PDFs out and bring them with you to your in-person appointment, along with your insurance card and a photo ID.
The same forms are available to submit online, on our secure, HIPAA-compliant patient portal.
- Pondworks Patient Contact Information Form
- Pondworks Practice Policies
- Pondworks Acknowledgement of Privacy Practices (our Privacy Practices are below, under “For Your Reference)
- Pondworks Consultation Informed Consent
- My Medicine Record
- Medical Review of Systems
- Pondworks Patient Portal Agreement
Telemedicine Appointment Forms:
- Pondworks Practice Policies for Telepsychiatry Appointments
- Pondworks Informed Consent to Telemedicine Consultation
For Your Reference (no signature required):
- Pondworks Privacy Practices
- Directions to Pondworks
- Pondworks – Insurance Terminology
- Pondworks – Behavioral Health Insurance Worksheet
- Pondworks – How to File an Out of Network Claim
- Stimulant Work Up
Other Patient Forms
Request of Information (ROI) Forms:
If you will be requesting medical records from another provider, OR giving permission for Pondworks to share confidential information (medical and/or billing) with someone, please complete the form below. PLEASE ASK US if you are confused!!
- Pondworks Request Records BK (Bernard Kim, MD)
- Pondworks Request Records HB (Holly Bellah, LMSW)
- Pondworks Request Records HyH (Hyojin Han, PMHNP-BC)
- Pondworks Request Records CJ (Chad Johnson, PMHNP-BC)
- Pondworks Request Records AL (Alexis Lucas, PA)
- Pondworks Request Records RM (Renea Mayville, PMHNP-BC)
- Pondworks Request Records CW (Candyce Willis, PMHNP-BC)
- MOCA Online Supplement V1.0
- Pondworks Patient Agreement for Psychostimulant Therapy
