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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
    • Staff
      • Administration & Reception
      • Medical Assistants
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      • Pediatric Care
      • Adult Care
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    Patient Portal

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 - Currently not accepting new Adult patients, check back next month
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

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
Review 4
REview 3
Excellent
Langworthy
REview 5
REview 6
THank you
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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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