• Nike Carli, LCSW-R

    Nike Carli, LCSW-R

    5500 Main Street, Suite 259, Williamsville, New York 14221 Phone: 716-633-6900
  • New Patient Office Visit Forms

  • Please provide the following as best you can. I appreciate your willingness to cooperate in helping me obtain your history and information.

    • Patient Information 
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    • Insurance Information: Please List All Insurances 
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    • I authorize the release of any medical or other information necessary to process any insurance claim(s). I also authorize payment of medical benefits for services described on above mentioned claim(s). I understand that I am ultimately responsible for payment of all services rendered and that I will be charged for appointments if canceled with less than 24 hours notice. In order to utilize insurance, I understand that all copays must be paid at time of service.

    • Patient History 
    • Prior Mental Health History

    • Family History

    • Social History

    • Military History

    • Legal History

    • Medical History:

    • Summery

    • Patient Bill of Rights, Confidentiality and Treatment Form  
    • Notice of Privacy Practices 
    • Authorization For Release Of Healthcare Info Primary Physician 
    • Purpose: Coordination of treatment.

      I hereby authorize the release of the above information from my record. I understand that the information to be released from my record is confidential and protected from disclosure. I also understand that I have the right to cancel my permission to release information at any time before it is released. I also understand that my consent to release information will expire:

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    • Use of E-mail Authorization 
    • Use of E-mail Authorization

      Many patients find it convenient and helpful to communicate with me by e-mail. While I welcome such communications, due to the inherent risks involved in e-mail use, it is important to understand the following:


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    • Photo ID 
    • Please provide a copy of a valid photo ID

      Upload - scan and upload using the "Browse Files" button below

      Fax to: 716-633-6902

      Mail to: Nike Carli, LCSW-R 
      5500 Main Street, Suite 259
      Williamsville, New York 14221                                                   
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    • Insurance Card 
    • Please provide a copy of your insurance card if applicable

      Upload - scan and upload using the "Browse Files" button below

      Fax to: 716-633-6902

      Mail to: Nike Carli, LCSW-R 
      5500 Main Street, Suite 259
      Williamsville, New York 14221                                                   
    • Browse Files
      Cancelof
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