Pondworks Psychiatry & Psychotherapy

Available Forms

Compliment A Pondworks Employee New Patient Form 1 of 7: Patient Contact Information New Patient Form 2 of 7: Practice Policies New Patient Form 3 of 7: Privacy Practices New Patient Form 4 of 7: Patient Portal Agreement New Patient Form 5 of 7: Review of Systems New Patient Form 6 of 7: Medications List New Patient Form 7 of 7: Consultation Informed Consent Questionnaire # 1 of 3: PHQ-9 Questionnaire # 2 of 3: GAD-7 Questionnaire # 3 of 3: Q-LES-Q-SF Telemedicine Consent Telemedicine Practice Policies

New Patient Form 3 of 7: Privacy Practices

Pondworks Privacy Practices Acknowledgement

The privacy of your medical information is important to our office. We understand that your medical information is personal, and we are committed to protecting it. We create a record of the care and services you receive in this office. We need this record to provide you with quality care and to comply with certain legal requirements.

Pondworks' Notice of Privacy Practices is a four page document, available as a pdf on our website, that describes the ways we may use and share medical information about you. It also describes your rights and certain duties this office has regarding the use and disclosure of medical information.

The Pondworks Privacy Practices document is available at www.pondworkspsychiatry.com/patient-forms. We encourage you to read and understand this document. Please contact us with any questions.

I have received, reviewed and agree to Pondworks' Notice of Privacy Practices. *

Yes

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