Patient Forms and Insurance Authorization

PATIENT FORMS AVAILABLE FOR DOWNLOAD

For your convenience our office forms are available for download to complete prior to your appointment with Dr. Klenck. Please select either a Word document or PDF of each form based on your preference.

PDF downloads will either initiate a download or open in a PDF web window depending on your operating system and web browser.

Cancellation Policies

The scheduling of an appointment involves the reservation of time specifically for you, so a minimum of 24 hour notice is required for re-scheduling or canceling an appointment. The full fee will be charged for sessions missed without such notification.

Agreement for Services

Billing and Insurance Authorization

Notice of Informational Practices

Optional - Authorization to Share Information

INSURANCE PRIOR AUTHORIZATION FORM

Please contact us with any questions regarding your appointment