Intake Release Form

Please fill out the form below or download the intake release form with the button above and fill it out at your convenience. Please email us if you have any questions. You can send completed paper forms to:

403 W. Cool Dr.
STE 107
Tucson, AZ 85704

or fax to:
520.329.8311

  • I understand that this evaluation may consist of formal testing of intellectual functioning. It may also include test of academic achievement, memory, language, speech, social/emotional functioning, and/or visual-motor coordination. I understand that psychological / educational / medical information can only be released with my signed consent under the following conditions (and are explained further in the HIPAA Notice Form that will be available upon request):

    • Such information may be sent to the referral source
    • Such information may be sent to assist in processing the insurance claim(s)
    • Such information may be sent in response to a court order
    • Such information may be sent when the patient has threatened harm to him / herself or to others
    • Such information may be sent in response to suspected child or elder abuse
    • Such information may be sent in defense of psychological practice

    I authorize and request payment of benefits from my insurance company directly to Southern Arizona Neuropsychology Associates, L.L.C. I agree that this authorization shall cover all services rendered until such authorization is revoked by me. I agree that a photocopy of this form may be used in place of the original.

    I understand that I am responsible for paying any and all charges not paid by my insurance carrier.

    YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO IT’S TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE THE RIGHT TO REQUEST THE HIPAA NOTICE FORM DESCRIBED ABOVE.

By clicking the submit button, you authorize the transmission of your personal health information to be sent over email. We take every effort to ensure that your information stays safe. All information is double encrypted and password protected.