6811 Kenilworth Ave Riverdale Park, MD 20737

301-412-1594

PATIENT INTAKE FORM

A Registered Caregiver is a person chosen by the patient to act as their agent in obtaining their medication at the dispensary
If yes, please provide documentation.

  • Other medical condition which is severe and for which other treatment have been ineffective:_____

PRIVACY POLICY AND PRACTICES

As a patient of William-Micah Psychatric Clinic:

I understand I have rights to privacy of my protected health information as defined by the Health Insurance Portability Act of 1996.

I have been made aware that upon request a copy of William-Micah Psychatric Clinic's privacy policy is available to me.

William-Micah Psychatric Clinic has made me aware of their right to change the terms of its Notice of Privacy Practice.