Thank you for taking time from your busy schedule to download our New Patient Forms. If you have any questions about these forms, feel free to call our office at (904) 997-7776 during working hours.

Patient appointments are not scheduled until all COMPLETED forms are received by the office, along with a LEGIBLE copy of the responsible party’s Driver’s License (or other VALID form of Government Issued Identification) and a copy of the insurance card.

      Child New Patient                                                                                                        

1) Patient Registration Form                                                                                      

2) New Patient Form-Child                                                                                     

3) Office Policies                                                                                                          

4) Release Authorization Form (to request a release of medical records)                   

5) Crisis Management for Self Pay Patients (if applicable)                                      

6) Credit Card Authorization

     Adult New Patient

 1) Patient Registration Form

2) Office Policies

3) Release Authorization Form (to request a release of medical records)

4) Crisis Management for Self Pay Patients (if applicable)

5) Credit Card Authorization

 

Our fax number is (904) 997-7057, alternately you can mail your forms to us or, you are welcome to bring the completed forms to our office Monday through Friday during our working hours. 

NOTE:

Former Patients, who received services from Dr. Farinas at Baptist Behavioral Care, wishing to resume treatment, MUST request to have their medical records transferred from Baptist Medical Center, to this current practice, for review PRIOR to completing forms to request a New Patient appointment in this practice.

When you contact Baptist Medical center and request your record be transferred, specify the following documents be sent over:  Initial Evaluation, Medication Log, all Labs and EKGs, any psychological test reports, the last 5 progress notes. That information can be mailed or faxed to my office.

Once your previous records are received by our office and reviewed – if resuming care is feasible, staff will call you and notify you to commence the New Patient Forms.

These forms MUST be completely filled out and returned to the office for review prior to your first appointment with Dr. Farinas being scheduled.

Being able to review the information you provide, before your first appointment with me, will maximize our time together. 

• Patient Registration Form

 

• New Patient Form - Child

       (filled out by a parent or a guardian) 
 

• Notice of Privacy Practice

 

• Office Policies

• Crisis Management Policy 

 

• Release Authorization Form 

       (to request a release of medical records)
 

• Policies for Court Ordered Evaluation

•  Credit Card Authorization

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All forms are provided in Adobe PDF format. 

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