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  • New Patient Form

    New Patient Form

    Complete this secure, HIPAA compliant form to determine insurance coverage before we schedule an appointment.
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  • If you don't have your drivers license at the moment, you can email it at your convenience to inquiry@telepsychhealth.com    Insurance companies, pharmacies, and federal law require us to verify your identity.

     

  • Insurance Information

  • Please upload your insurance information so we can check your benefits / coverage.

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  • If you don't have your insurance card at the moment, please email it as soon as possible to inquiry@telepsychhealth.com 

  • If you are a dependent of another person for your insurance coverage, please fill in the primary member information:

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  • Please note that we do NOT prescribe controlled substances such as Adderall, Ritalin, Xanax, Klonopin, Ativan

     

  • Please answer the next two questions considering the PAST MONTH...

  • TelepsychHealth collaborates with Headlamp Health which allows us to gather your historical medical records, track your mood and behaviors, and build your awareness of how these feelings may contribute to your overall health and wellbeing. You will then be able to access this record from Headlamp Health. If you would like to learn more: https://www.headlamp.com/patients.

    Do you want to give permission to Headlamp Health to obtain your historical medical records?

  • Once you have registered to be a new patient in our practice, you will get a text message from Dr. Bruce Bassi at Headlamp Health to invite you to download the app.

  • Please note, a disability evaluation is a specific type of evaluation that we do not perform due to practice restrictions. If you are receiving any money through workers' compensation, you cannot be seen in our practice. By submitting this form, you attest that you are not receiving any money through workers' compensation. 

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