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Patient Forms


 

Medical Records Release

Beautiful Mind Behavioral Health Services, PLLC will gladly provide records to our patients' other medical providers or legal representation. In order to protect our patients' privacy and to ensure all steps are taken to follow HIPAA guidelines, We do ask, if our form is not signed in our office and witnessed by one of our staff members, that the Medical Records Release form to be notarized.

Medical Records Release

Patient Registration

If you are interested in becoming a new patient, please call our office at 336-438-2525 to become registered in our electronic medical records system. Once an account has been created for you, we will schedule an initial evaluation appointment with a provider of your choice. New Patients are encouraged to download our New Patient Packet. Please read it carefully, sign or initial where indicated, and bring it with you to your initial appointment. Patients whose information has recently changed are also encouraged to resubmit a new package with all their updated information.

**If there are any Court/Custody/Guardianship/Health care Proxy forms please bring to the first appointment, or patient may not be seen**

Patient Registration 

The consent for Minor Treatment

Download the consent for Minor treatment form

Consent for Minor treatment

Clients Rights and Privacy Practices

Our staff at Beautiful Mind Behavioral Health Services including providers and counselors, continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the "Privacy and confidentiality Rules". We strive to achieve the highest standards of ethics and integrity in performing services for our patients. It is our policy to properly determine appropriate uses of Personal Health Information (PHI) in accordance with HIPAA. We are required by law to maintain the privacy of our patients and to provide individuals with the notice of our legal duties and privacy practices with respect to PHI, including HIV and Substance Abuse status. Therefore, pursuant to General Statute (GS) 130A-143, HIPAA Regulation 164.512 and Policies 42CFR and 45CFR, we have implemented a Compliance Program that will help prevent any inappropriate use of PHI.  Copies of our "Client Rights and Privacy Practices" may be viewed and/or downloaded below:

Client Rights and Privacy Practices 

Referral from other medical providers

Download the referral form and fax to 336-438-2526, Please attach to the referral form a Consent for Release of Information form signed by the patient in order for our office to collaborate with referring provider.

Referral from other medical providers

Emergencies

In the event of a life-threatening emergency, patients are asked to call 911 immediately. We have an “On-Call” provider available 24 hours a day, 7 days a week. For any non-life-threatening urgent situations, please call our after-hours answering service at (336)438-2525, option 1, to reach the on-call provider. 

 
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