Forms

Once you are scheduled to see Dr. Goldfarb, please submit the completed forms by e-mail or by fax: 212 570-1077. Please do not send forms without a confirmed appointment.

New patient forms:

• Psychiatric and Medical History Form
• Electronic Confidentiality Communication Notice
• HIPAA Model Notice of Privacy Practices
• HIPAA Release of Information (Privacy Authorization Form)

Medicare forms:

• Medicare Addendum to Opt-Out Letter
• Medicare Private Contract

Financial forms:

• Appointment Cancellation Policy
• Credit Card & EFT Authorization Form
• Email and Payment Reference
• The No Surprises Act

Self-report symptom forms:

• Adult ADHD Self-Report Scale
• Binge Eating Disorder Screener
• Daily Alcohol Self-Monitoring Log
• Generalized Anxiety Disorder Scale
• Quick Inventory of Depressive Symptoms
• Rapid Mood Screener