FORMS AND RESOURCES

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Patient Forms

Fill-out the following forms prior to the initial session. Tap or click on the patient form link and download or save the form to your device. Open the saved form and enter your information. When finished, save the completed form again to ensure your data is kept.

You can submit your form 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 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.

ADULTS (Ages 18 years or older)

CHILD OR ADOLESCENT

ALSO REQUIRED:

  • Notice of Patient’s Rights and Responsibilities, and Privacy Practices as required by the Health Insurance Portability and Accountability Act (HIPAA) OF 1996 (English & Spanish)
  • Acknowledgement regarding Cancelled and Missed Appointments (English & Spanish)
  • Coordination of Insurance Benefits (English & Spanish)

Important Documents:

  • 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.

  • Release of Information Authorization (English & Spanish)
  • This form must be completed and signed in front of a Notary Public, if NOT witnessed by an authorized HBI representative. Read carefully the INFORMATION FOR INFORMED CONSENT detailed on the form. Pursuant to Nevada Laws, you may have to pay a fee per page due prior to the release of patient records.

  • Patient Guide (English) (Spanish)
  • This document provides some useful information on your first visit. You can also go to the Member/Patient page for more information.


Screening Tools

These are not intended to replace professional clinical judgement. CONSULT A PROFESSIONAL CLINICIAN for proper diagnosis.

Provider Forms

Network Enrollment

Clinical Forms

NOTE: Providers are responsible for using HIPAA compliant technology when saving and transmitting protected health information (PHI).