About This Form

This form is intended for use by patients who have already scheduled an appointment with Dr. Tate. To schedule an appointment, please call (646) 413-1825

 

Patient Registration Form

  • Contact Information

  • Health Care Insurance Information

  • Primary Care Physician Information

  • Please Check One

  • Assignment of Benefits

  • I authorize the payment of medical benefits to the named provider for psychiatric evaluation, treatment and or services.
  • Release of Information

  • I authorize the release of any psychiatric evaluation and/or treatment information required to process claims of payment for treatment and services.
  • Cancellation Policy

  • If you must cancel an appointment, Mind Solutions Psychiatry, P.C. requires twenty-four hour cancellation notice in order to avoid a missed appointment fee, which will be equal to the full amount of the treatment session charge. I understand that missed appointments are not covered by my insurance provider plan, and further agree that I am responsible for the full fee for any missed session if I fail to give twenty-four hour cancellation notice.