FORMS

HIPAA Compliant Communications regarding the use of email. If your email server uses TLS then your emails should be secure. If you do not know the answer to this then it is highly recommended for you to create an account on the following secure portal. Go to http://securesend.luxsci.com. You will use your existing email account and create your own password. Send all communications from the secure portal to Laura at laurabiller@luxsci.net. If you need assistance with the intake forms or have billing questions please email Laura at laurabiller@luxsci.net, using the secure portal.

Please complete the following forms and email to Laura at laurabiller@luxsci.net through the secure portal (preferred) or send via U.S. Mail to Rob Yee, P.O. Box 28415, Seattle, WA 98118.

Basic Information Form

Service Agreement

New Patient Registration Form

Adult Concerns

 

HIPAA Compliant Communication Policy

Consent for Communications by non-HIPAA compliant methods

Telehealth Counseling Agreement

Crisis Plan

 

Authorization for Credit Card Use

Late Cancellation and Missed Appointment Policy

 

Notice of Privacy Practices

Rights and Exceptions to Privacy

Policy on Legal Matters

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The following forms are optional. Please select the appropriate form(s) from the following list. Complete the form(s) and send to Rob via the secure portal (preferred) or send via U.S. Mail to Rob Yee, P.O. Box 28415, Seattle, WA 98118.

Authorization for Release of Information

Couples Agreement Form