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          • 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
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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 (0-18) 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

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 Opt Out
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

TEL (207) 563-3366

80 RIVER ROAD
NEWCASTLE, MAINE 04553

FAX (207) 563-3393

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