Required Telemedicine/Telehealth Forms
DrGmed, Inc. Telehealth Patient Printable Forms
Please review our patient forms below so we can learn more about your medical history to better learn how to treat you.
Release of Information Form - Optional; Complete if you would like us to communicate with anyone about your care.
Consent for Psychotherapy Recording - Play Therapy only (Required for 6 to 12-year-old)
We cannot process your intake paperwork until we received all of the required forms and a copy of your insurance card and picture ID.
Please fax all the required forms and a copy of your photo ID and insurance card to 949- 577-4327. Please do not email insurance cards or other confidential information as email is not a secure method of transmission. Once we have all forms and have verified your insurance coverage, we will call you to schedule an initial assessment.
Notice: Due to New Mexico, Arizona, Florida, Utah, California and Texas health care laws, the ROI form should be completed by clients age 13 and up if a parent or other party will need to communicate with us about scheduling or other information:
In order to protect our patient’s privacy and confidentiality, our platform is HIPAA compliant. Our technology is at no cost to our patients. Our patients will need to use their computer or smart phone to connect with us. Therefore, a good internet connection or cell reception is necessary.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE REVIEW CAREFULLY:
Ways in which I may use and disclose your protected Health information:
I may use and disclose at my discretion your medical records for each of the following purposes only: treatment, payment and health care operations.