Notice of Privacy Practices
Release of Information
Legal Name (Last)
Legal Name (First)
Legal Name (M.I.)
Date of Birth
May Dr. Grant or his associates send you a letter to your home address?
May Dr. Grant or his associates contact you at this number? Leave a VM and/or Text?
May Dr. Grant or his associates contact you at this email?
May Dr. Grant add your email to his blog on All Things Psychology?
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Address
If you want insurance claims filed, please complete below:
Insured (i.e. holder of insurance)
Insurance Carrier Name (e.g. Anthem) and Provider Relations phone #
Insured's Birth Date
I authorize the release of treatment data, including drug and alcohol information, if required by my insurance. I also authorize all behavioral health benefits payable under my insurance policy to Matthew G. Grant, Psy.D., HSPP-NorthStar Psychological + Consultation Services, LLC so that they may be applied to my account. The remainder left unpaid is my responsibility unless otherwise stated. Even if you're using your EAP benefits, you still must complete the entire form.
Name of Insured (serves as signature)
Date (Today's Date NOT your DOB)
Type the letters from the image.
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Indianapolis, IN 46202
317-572-7847 (ST4R) Call/Text
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