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FORMS: (click on image to see forms)
New Patient Intake Form (everyone)
Consent for Treatment (everyone)
Referral Form (doctor referred patient/ insurance required pre-authorization patient)
HIPPA Form (everyone)
Acknowledgement Notice of HIPPA Form (everyone)
HIPPA Signature Form (everyone)
Work Compensation patients only:
Work compensation Authorization Form (work compensation only)
Work Injury Form (work compensation only)
New Patient Intake Form
Consent for Treatment
HIPPA Form
Acknowledgement Notice of HIPPA Form
D.C. office: (240)-778-4568
M.D. office: (301)-838-0524
(240)-778-4568
Location
DC Office:
1010 Vermont Ave. N.W. #501 Washington, DC. 20005
MD Office:
9075 Shady Grove Ct.
Gaithersburg, MD 20877
DC office:
Mon 11AM-4PM
Tue 11AM -6:00PM
Wed Closed
Thurs 11AM- 6:30PM
Friday Closed
Satur Closed
Sun Closed
MD office:
Tues 9:00AM - 6:00PM
Wed 9:00PM - 6:00PM
Thurs 9:00AM - 6:00PM
Friday 12PM- 5PM
Sat 9:00AM - 5:00PM
Sun Closed
COVID19 consent Form (everyone)
HIPPA Signature Form
COVID19 consent Form (everyone)
** Work compensation patients must bring a letter of approval. Information such as case manager, adjuster, company, etc maybe required. Letter of approval needs to have practitioner's name, time and date of approval treatment. Please have all your information ready before delaying of treatments.
**Please read carefully as there are new HIPAA guidelines
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