Nancy C. Wheeler, M.D., P.A. : Initial Appointment Forms

N A N C Y C. W H E E L E R , M . D . , P . A .
P S Y C H I A T R I S T

Initial Appointment Forms

Patient Information Form (in PDF)
Please fill out this Patient Information Form as best as you can and bring it to the inital appointment.

HIPAA Privacy Form (in PDF)
This explains your rights to privacy under HIPAA.

Acknowledgement of Receipt of HIPAA Form (in PDF)
Please sign and date this form. It acknowledges that you received a copy of the HIPAA.

Release of Information Form (in PDF)
This form, when completed and signed by you, authorizes me to release protected information from your clinical record to the person(s) you designate.

Kissing Bridge, Waterville, Vermont
Painting by Bill Schmidt

*If you have any trouble with these forms, don't worry. Just come ten minutes early for your initial appointment, and Linda will have the same forms. She can review them with you. Dr Wheeler is happy to answer any questions as well.*