Consumer Registration Form /
Formulario de Registro Consumidores
Every new SummitStone Health Partners consumer must fill out this form. It requests basic information about your name, address, birth date, etc.
Release of Information (ROI) /
Divulgación de informacións
This form allows us to communicate with anyone (i.e. probation, DHS, your medical providers, family members, etc.) that you would like to have us coordinate treatment /communicate with.
ROI Request to Communicate Via Email/
Divulgación para la Comunicación por Correo Electrónico (Email)
This form allows us to communicate via Email with anyone (i.e. probation, DHS, your medical providers, family members, etc.) that you would like to have us coordinate treatment /communicate with.
Disclosure Statement and Consent to Treat Form /
Declaración de Divulgación y Consentimiento para Tratar Forma
This form provides information about your rights as a client, your agreement to participate in treatment and/or permission for a minor child to be treated.
Joint Notices of Privacy Practices /
Aviso conjunto de preácticas de privacidad
This notice tells you how health and drug and alcohol information about you may be used and disclosed and how you can get this information.
Request for Access to Protected Health Information /
Petición de Acceso a Información Protegida de Salud
This form is required to be completed by the parent, guardian or legal custodian of a minor child.
Financial Agreement/
Acuerdo Financiero
This form provides information about our financial policies and payment expectations.
Informed Consent During COVID-19/
Acuerdo Financiero
This form provides information about our services during the COVID-19 health crisis.
Medical Decision Making Form /
Formulario toma de decisiones médicas
This form is required to be completed by the parent, guardian or legal custodian of a minor child.