Patient Forms

New Patient Forms

Tap the Intake Paperwork button below to sign via Docusign. Completing this prior to your appointment will save you time and help avoid delays in seeing your provider. 

Alternatively, if you see your provider’s name below, please tap the appropriate link.

Sofia Encarnacion, MD

Intake Paperwork

Michael Ferguson, MD

Intake Paperwork
Guardian Forms for Intake
(if you are completing on the patient’s behalf)

Robert Fischer, MD

Intake Paperwork
Guardian Forms for Intake
(if you are completing on the patient’s behalf)

Mikhail Meyerovich, MD

Intake Paperwork

Request to Release Information

To manage the optional transfer of your protected health information, make your request below. 

For patients requesting records from other clinicians to SBBH

Authorization for Release of Medical or Mental Health Information | En Español

Alternatively, if you are the patient’s guardian:
Form | En Español

For patients requesting SBBH to send a copy of their records:

Authorization for Release of Medical or Mental Health Information | En Español

Alternatively, if you are the patient’s guardian:
Form | En Español

Financial Responsibility Documents

To authorize payment on behalf of a patient, see options below.

If you wish to authorize SBBH to charge a credit card for the patient’s cost at the time of service:

Credit Card Authorization | En Español

If you agree to cover the cost of services that your insurance company may deny:

Assumption of Financial Responsibility | En Español

If you are willing to guarantee payment for the exceptional situation in which a third party is making an appointment for a patient:

Authorization for Third Party Appointment Scheduling | En Español

Complete our simple intake form to see if your insurance plan covers SBBH services