Update and Release Forms
2024 Mindful Psychiatry Update Form
This form provides us with consent for treatment in 2024 and consent to bill your insurance or you in 2024, etc. If you are an existing patient, you MUST complete this form before your first appointment or any services (such as refill requests) in 2024 with Mindful Psychiatry. This should be completed at least 48 hours before your appointment to allow our team time to process and upload forms.
Manual OPTION:
STEP 1. Please download the form below and fill it out on your computer or print it and fill it out by hand.
** Make sure to COMPLETE and INITIAL ALL necessary boxes and sign as incomplete forms will need resubmitted completed ***
**** Filling the pdf fields on your computer does not send it to us. There will be no save or send button. Once the blank spaces are complete, you must print the document or save it to your computer as a pdf and then send it to us*****
STEP 2. SEND US BACK the completed form:
A- as a pdf on your secure Spruce account,
B- our office fax (321) 616-8126
C- Our email is not encrypted or secure - but it does receive pdf - office@mindfulpsychiatry.sprucecare.com
D - By mail - 1565 N Harbor City Blvd., Melbourne, FL, 32935
STEP 3: IF YOUR INSURANCE HAS CHANGED: send a copy of your new insurance ID card front and back on your Spruce account
STEP 4: Any changes in credit cards should be made directly in your MYIO portal
- if you have issues sending there, you may still send securely on Spruce or over the phone.
Download the PDF form below AND RETURN IT TO US COMPLETED ON SPRUCE:
Release of Information: to allow communication with others
HIPAA Release of Information
The Release of Information allows communication between your provider and any other chosen party. Should you choose to revoke this permission, you may submit a written request to revoke the permission granted by this form at any time.
If you need information shared, please reach out and we will send you a form on your MYIO Portal.
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