New Patient Forms:
Please click on each form to download, print and fill out.
2. ADULT ADHD SELF REPORT SCALE (ASRS-v1.1) SYMPTOM CHECKLIST (fill this out only if you think you might have ADD (Attention Deficit Disorder) or ADHD (Attention Deficit Hyperactivity Disorder)
4. AUTHORIZATION TO USE AND DISCLOSE PERSONAL HEALTH INFORMATION (Required if patient is over 18 and wants to give another individual access to some or all of their protected health information. This includes being able to make payments on a patient account, make, confirm or cancel appointments on the patient's behalf and speak to Dr. Holmberg regarding a patient's care. Please specify on form which information you wish to disclose.)
5. CREDIT CARD AUTHORIZATION (only needed if patients will not be paying for their own visits. Those not paying for their own visits will also need to fill out an authorization in order to disclose billing related information)
6. MEDICARE OPT-OUT CONTRACT (Medicare patients only age 65 or older)
Please be aware that Dr. Holmberg is a non-Medicare or "Opt-Out" Provider. It is Medicare's policy that if you are on Medicare and you choose to see a non-Medicare provider, the patient and the non-provider must sign a contract stating that you both agree to NOT request reimbursement from Medicare for your visits. If you are enrolled in Medicare, you and Dr. Holmberg will need to sign the form above.
For an updated Clinical Fee Schedule, please contact our office.
Please be aware that Dr. Holmberg is a non-Medicare or "Opt-Out" Provider. It is Medicare's policy that if you are on Medicare and you choose to see a non-Medicare provider, the patient and the non-provider must sign a contract stating that you both agree to NOT request reimbursement from Medicare for your visits. If you are enrolled in Medicare, you and Dr. Holmberg will need to sign the form above.
For an updated Clinical Fee Schedule, please contact our office.