Accurate diagnoses for effective treatment planning

Forms

New Patients Forms

All forms must be fully completed, signed and submitted prior to scheduling your first appointment. You can submit forms by website, faxing, and by mailing. To make this the process smooth and efficient, we have made all documents available as downloads right here on our website.

This web site uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.

Medication and Diagnostic Evaluations

New Patient Packet

Introduction to BBMC’s practice and policies as well as registration and consent forms.

Require a photo ID and insurance card.


Therapy

New Patient Packet — Therapy

Introduction to BBMC’s practice and policies as well as registration and consent forms.

Require a photo ID and insurance card.


Consent for Treatment — Belén Abrego

An authorization for release of Protected Health Information and acknowledgement for Belen Abrego, MS, AMFT, APCC is performing clinical counseling services for continued education.


Consent for Treatment — Jacqueline Galindo

An authorization for release of Protected Health Information and acknowledgement for Jacqueline Galindo, AMFT is performing clinical counseling services for continued education.


Consent for Treatment — Tracy Cappel-Rice

An authorization for release of Protected Health Information and acknowledgement for Tracy Cappel-Rice, M.Ed., APCC is performing clinical counseling services for continued education.


Protected Health Information Forms

Authorization for Release of Records

This form is required if you should choose to authorize our office to release Protected Health Information to an outside provider or agency.

Require a photo ID.


Authorization to Obtain Records

This form is required if you authorize BBMC to obtain Protected Health Information from an outside provider or agency.

Require a photo ID.


Provider Referral Forms

Adult Intake Form

This form is required to be completed for all adults being referred to the practice.


Child & Adolescence Intake Form

This form is required to be completed for all children and adolescence being referred to the practice.


Contracts with Sante , IPA

Treatment Authorization Request

This form is required to be completed to obtain authorization for mental health treatment for members under our capitated health plans with Sante, IPA.

BBMC is a corporation which contracts with physicians and other duly licensed providers for the provisions of psychiatric, mental health and non-medical mental health services. We have a capitated agreement with Santé IPA for the following health plans:

Blue Shield 65+
Brand New Day
Community Care Health
United Health Care Medicare Advantage


Submit Forms

To upload documents, fill out forms with Adobe Acrobat. Save, scan or take a photo of the document you want to upload. Prior to uploading forms, verify they are fully completed and have signatures on required areas.

Upload from your computer.

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Photo ID

Insurance Card

Can select up to two images to submit