contact-new-1

First Name:

Last Name:

Your phone number:

Relationship to the patient?:

Patient's name:

Patient's email:

Your DOB*:

What type of question do you have?:

Type of question do you have?:

What type of appointment would you like to cancel:

When is your appointment:

Name of provider

Reason for cancellation?

Our clinicians are also booked out far in advance and have limited availability, are you sure you would like to cancel?

Would you like to reschedule your appointment instead?

Please provide minimum of (three) 3 date and time options for rescheduling

Please be aware that clinicians availability is very id=18limited. We will try to accommodate your request, however, if the slots are not available we will offer you the next available slot. We highly recommend you to book an appointment as soon as possible.

What type of appointment would you like to reschedule:

When is your appointment:

Name of provider

Reason for reschedule the appointment

Our clinicians are also booked out far in advance and have limited availability, are you sure you would like to reschedule?

NNew U Therapy Center has a 2-business day cancellation policy for all new and established patients. Our business hours are Monday through Friday 9 a.m. to 6 p.m. although some clinicians see clients after hours and on weekends. If a patient fails to provide adequate notice, a no show/late cancel fee of $100.00 will be assessed. For example, Saturday and Sunday clients will need to cancel their appointments by the end of Wednesday. Monday clients will need to cancel their appointments by the end of Wednesday of the previous week. Should you miss or cancel two sessions in a month or in a row, your treatment will be considered terminated without notice and you will be returned back to the waiting list. Medication refills will not be prescribed without an appointment, please ensure you reschedule your appointment immediately.

Please provide minimum of (three) 3 date and time options for rescheduling

Please be aware that clinicians availability is very limited. We will try to accommodate your request, however, if the slots are not available we will offer you the next available slot. We highly recommend you to book an appointment as soon as possible.

Medication(dosage):

Is this a medical emergency?

If you feel this is a medical emergency, please call 911 or go to your nearest urgent care or emergency room

Side effect (please add as many details as possible)

When did this side effect start? How long have you been having the side effect for?

Medication Requested and dosage

Most medication refills will require a monthly appointment with your Primary Provider.

Refill requests will not be processed if Patient does not have a follow up appointment scheduled.

If you need a controlled substance evaluation appointment, please submit your request on our appointment tab or call the office phone number at (818) 600-2034.

Controlled substances, such as benzodiazepines and some ADHD medication will only be filled for a 30 day max supply as per state standards

Days of medication left on hand

*refill request may take up to 72 hours to complete

What type of billing question do you have?

Name of Insurance

Id number

Group number

Plan type: (HMO, PPO, EPO, etc)

Address to Submit the Claims

Who is the primary insured?

Relationship to the Primary Subscriber

Primary Subscriber DOB*:

Please indicate your concern

Types of Medical Record request

Describe your Medical Record request

If you selected "Other" option

Patient's provider

Is the request for Medical Record for the patient themself or is there a signed Authorization to Release form already submitted in the patient’s file?

Patients need to be established with their provider minimum 3 months for any paperwork that requires disability related recommendations.

Allow at least 10 business days and up to 30 days for the completion of any documents.

Fees will be charged by your provider for the production of records, letters; depending on the type of request, your provider may set a flat fee or a fee in increments of 15 minutes at a rate of $250.00 per hour for therapist and $500.00 per hour for psychiatrist or nurse practitioner.

Fees must be paid prior to the release of records.

Address:

Can we leave a voicemail?

Best time to reach you?

Current Program Enrollment

Date of Incident

Time of Incident(if known)

Name of Person (s) Involved

Please describe the incident or provide your concerns/suggestions in as much detail as possible

By signing my name below, I attest that all the responses I have provided above are true

Thanks for contacting