The following three forms are available for your convenience:
1. HIPAA Policy and Agreement Form (download and print)
2. Medicare Beneficiary Contract (download and print)
3. Patient Registration Form: please fill out below and click “Submit.”
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Will you take a moment to let me know how you learned of my practice? By whom were you referred?
Payment Policy: As the client, the health care insurance is yours. Insurance coverage varies widely, and it is your responsibility to know which outpatient psychology services are covered, and how that impacts your payment responsibility.
There are times when appointments are missed because of circumstances or illness. While Dr. Wolfe is happy to work with you to re-schedule, she may charge for appointments that are missed without 24 hours advance notice of cancellation.
Please understand that you are responsible for charges for services provided. In the event of non-payment, Dr. Wolfe may involve a collections agency, and you would be responsible for any additional fees related to that service.
It is Dr. Wolfe’s practice to give to the client the forms you will submit to your insurance for payment. If you request that Dr. Wolfe have contact with your insurance company, or that she submit claims to that entity, you hereby authorize that Dr. Wolfe release information as required by the insurance company to authorize services and/or to process claims for the payment of benefits.
Electronic Signature: Please type your first and last name
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Payment Policy.
Old Georgetown Office Park
7988 Old Georgetown Road
Bethesda, Maryland 20814
Tuesday 8 - 5
Wednesday 8 - 7
Thursday 8 - 5