We created our forms with Adobe Acrobat extended features to enable users to enter data, save the completed form, print, and attach to e-mail. For best results, it is recommended to use the latest version of Adobe Acrobat Reader - download for free.
IMPORTANT THINGS TO REMEMBER WHEN USING THESE FORMS
Only the top 5 Patient Forms are fillable and they are required prior to the initial session.
You can open and fill-out these forms using most computing devices, tablets, and smartphones but the way they work would depend on the OS of your device.
For a better experience, it is recommended to use a desktop or laptop computer when working with these forms.
If you're using an Android or iOS device:
Tap or click on the patient form link and download or save the form to your device.
Then open the saved form to enter your information.
When finished, save the completed form again to ensure your data is kept.
You can submit your completed form(s) back to us by one of the following methods:
1) Attach the saved document to your e-mail and send to Intake@hbinetwork.com.
2) Print and mail (at least one week prior to the initial session) to: Human Behavior Institute - 2740 S. Jones Blvd, Las Vegas, NV 89146.
3) Print the completed forms and submit them to the front office on the day of your first visit, at least 15 minutes prior to your appointment.
If you need assistance or have questions about the forms, please call (702) 248-8866 ext. 200.
ADULTS (Ages 18 years or older)
CHILD OR ADOLESCENT
- Notice of Privacy Practices(English and Spanish) The patient must retain a copy of this notice as required by the Health Insurance Portability and Accountability Act (HIPAA) OF 1996
- Acknowledgement regarding Cancelled and Missed Appointments (English and Spanish)
- Financial Responsibility Agreement (English and Spanish) This document must be submitted with the insurance ID(s) corresponding with the insurance plan(s) provided, and signed in front of an HBI authorized personnel.
- Patient Guide (English) (Spanish) Whether you’re a first-time or returning patient, we would like you to fully-engage in your experience at HBI. We prepared this material to guide you on your journey. It is important that you read this Patient Guide and understand the value of your informed decision to participate in your treatment. You can also go to the Member/Patient page for more information.
- Release of Information Authorization (English and Spanish) This form must be signed in front of a Notary Public, if NOT witnessed by an authorized HBI representative. Please read the INFORMATION FOR INFORMED CONSENT carefully. Pursuant to Nevada Laws, you may have to pay a fee per page due prior to the release of patient records.
- Medication Agreement regarding Prescribing Controlled Substance (English) (Spanish) If you are being prescribed a controlled substance, this form is required to be signed in the office during your medication management appointment.
These are not intended to replace professional clinical judgement. CONSULT A PROFESSIONAL CLINICIAN for proper diagnosis.
NOTE: Providers are responsible for using HIPAA compliant technology when saving and transmitting protected health information (PHI).