Please read the following important points carefully as they are all relevant to your care:
A) Please complete the following 6 forms prior to your first Appointment:
1) New Patient Registration Form: http://pdf.ac/8bYBPS
2) Consent to Treatment Form: https://pdf.ac/4w9UHC
3) Acknowledgement of Privacy and Release Form: http://pdf.ac/5KUHBC
4) Either Insurance Contract Form: http://pdf.ac/6K7eQW
Self-Pay Contract Form: https://pdf.ac/1rND2Z ( which ever applies to your case).
If needing suboxone treatment, Suboxone Treatment Contract Form: http://pdf.ac/a2d4za
5) Supplemental Services and Electronic Payment Agreement: https://pdf.ac/3e8wYq
6) Either Intake Form ADULT: http://pdf.ac/7Pb2c6
Intake Form CHILD/ADOLESCENT: http://pdf.ac/2Ed25O
Note: 1) A clinical nurse will assist with this process, if necessary. 2) If using a smart phone to complete the form, please download FORMFILLER for the best experience.
BE SURE TO FILL OUT EACH FORM COMPLETELY. Click DONE to submit.
B) If applicable, you MUST send us a copy( front and back) of your insurance card, in one of three ways:
-By fax, to 573-271-5108, or
-by email, to email@example.com, or
-via your wecounsel portal, or
-by mail, to Success Health System LLC, P.O. Box 716, Columbia, MO 65205.
C) You will Receive an Invitation to join Wecounsel, our secure communications and Payment System. Please follow the Instructions. If payments will be made with a credit card, please enter details when prompted.
D) You may receive communications and documents from PDFFILLER. If you do, please visit www.pdffiller.com and register by using your email and creating a strong password. Then address what ever task is required( fill a form or sign a document...).
E) Finally, for Follow Up Appointments: Please complete your follow up form prior to your appointment: http://pdf.ac/9IoIE0
Thank you for choosing Success Health System for your health care needs, where we've made patient care our utmost priority. It is our pleasure to serve you.
Moses Tabe Ambilichu MD, Board Certified Psychiatrist,