NEUROPSYCHOLOGY FORMS
Download & print Forms
In order to save time when you come to your appointment, you may print out and complete the registration forms ahead of time. Or, if you prefer, you can just complete the paperwork at the time that you arrive for your appointment.
Neuropsychology Evaluation
- Notice of Privacy Practices
- Privacy Practices Acknowledgement
- Consent for Neuropsychological Evaluation
- Release of Health Information
- Registration
- Covid Informed Consent
INDIVIDUAL FORMS
Registration Form
This form includes some basic information about you.
Release of Information Form
This form specifies which physicians (or others) you allow us to contact/share information with. For patients who will have a neuropsychological evaluation, typically you would list the referring physician, and other physicians who would need to know the results (e.g. your primary care physician).
HIPAA policies
This is information about privacy policies for your records (nothing to sign).
HIPAA Acknowledgement Form
This is a document confirming that you have been given the above HIPAA policies.
Consent Form (for neuropsychological testing)
This document provides informed consent for neuropsychological testing.
COVID Informed Consent Form
This document provides informed consent for in-person appointments
QUESTIONS?
Feel free to call our office for more information.
Contact Dr. Laila Spina
Office ADDRESS
Eaton Square – Villa Professional Plaza
438 Hobron Lane, Suite #415
Honolulu, Hawaii 96815