Associates, PLC  
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Welcome to Hearthstone

Welcome to our forms page.  You can print off the forms that you will need to fill out and bring with you on your first visit.  The only thing you will need to provide is your insurance card, if you are using insurance.  On the left side of this screen you will see the word “Forms” and if you move your mouse over the word a drop down menu will appear. 

If you are a client who is an adult and are covered under an insurance policy either by you or your spouse you will use the “Adult Client Intake Form”.  There will also be a HIPPA form for you to read or print off to keep and a Consent form for you to print off and sign.  The only two forms you need to bring with you are the Adult Client Intake Form and the Consent Form.  

If you are a client who is and adult or child but are covered under a parent’s insurance policy you will need to fill out the “Dependent Client Intake Form”.  Please make sure to fill this form out completely.  There will also be a HIPPA form for you to read or print off to keep and a Consent form for you to print off and sign.  The only two forms you need to bring with you are the Dependent Client Intake Form and the Consent Form.

If you are paying privately for your visit you will then select the Private Pay Form.   There will also be a HIPPA form for you to read or print off to keep and an Office Policy Form you to print off and sign.

The Release of Information form only needs to be filled out and brought in if are requesting that we communicate with or provide medical records to someone (i.e.; an attorney, work, school).  Otherwise, you will not need to print off this form.

If you have any questions please do not hesitate to call our office manager Jami at (515) 279-2834 ext 1.    


Disclaimer:
 This website is not designed to respond to emergencies.If this is an emergency, please contact your local emergency room or call 911 for assistance.

 


 

QUESTIONS?
If you have any questions please contact our Office Manager Jami 515-279-2834 ext 1

LOCATION
950 Office Park Rd. • Suite 321
West Des Moines, IA 50265
515.279.2834 • Fax 515.279.4168

Click Here for a Map