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  • Learn About Lifespan
    • Our Practice
      • About
      • Hours
    • Providers
      • Michael H. Clark, MD
      • Rebecca E. Clark, MS, LMFT
      • Shane B. Lovley, MS, PA-C
      • Haley E. Doak, MS, PA-C
      • Steve E. Feder, DO
      • Sarah J. Scott, MD
    • Staff
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      • Clinical Staff
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      • Pediatric Care
      • Adult Care
      • Counseling
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Forms

(Please click on any form or question to view and/or to print.)

Introductory Information for Our Patients

Office Information for New Patients


New Medical Patient Forms

New Adult Intake Forms
New Pediatric-Teen (0-17) Intake Forms
Notice of Patient Privacy (HIPAA)  (to view or print)
Patient Consent Release/Financial Policy (included in packet above)
Medical Records Release form  (included in packet above)


New Counseling Patient Forms

–  Please DO NOT send paperwork until you have a confirmed appointment with Rebecca Clark, LMFT.  Thank you! – 

New Counseling Patient Packet
Telementalhealth Informed Consent
Permission to Record
Good Faith Estimate/Out of Network
Release of Information-Couples/Family Counseling
Release of Information-Individual Therapy
Primary Care Provider Release
Medicare Private Contract to opt for non medicare provider

Osteopathic Manipulative Treatment Patient Forms

OMT Intake


Miscellaneous forms or information (to view or print)

Forms for Annual Exam/Physical
Pediatric Annual Visit Forms
Forms for Annual Wellness Visit
HealthInfoNet Info / Opt Out form
Flu Vaccine Consent Form
Flu Vaccine Information Statement (CDC)
What is an ABN?
ABN form
What is a PA?
Advanced Directive form
What is Marriage and Family Therapy?
Patient Satisfaction Survey form
Insurance and Payment Policies
Driver Medical Evaluations
Preventative Exam Information
Disability Placard
Review 4
REview 3
Excellent
Langworthy
REview 5
REview 6
THank you

HOURS

8:00 am - 4:30 pm

80 RIVER ROAD
NEWCASTLE, MAINE 04553

TEL (207) 563-3366

FAX (207) 563-3393

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