Patient Form Downloads ADHD Checklist Adult ADHD Checklist Mood Disorder Questionnaire Physician Adult Assessment Form Physician Child Assessment Form New Patient Application Adult Self-Report Scale - V1.1 Vanderbilt ADHD Diagnostic Parent Rating Scale HIPAA Acknowledgement Patient Information/Registration PHQ-9 Patients' Rights and Responsibilities Statement Medical Record Release and Authorization   Patient Form Guidelines   General Administrative Forms Listed below are several of the forms you will be required to complete for admission into our practice at Evansville Psychiatric Associates. Please feel free to print and complete these forms prior to your first appointment.   New Patient Application Forms Use this when first contacting EPA to set up a new patient appointment. (Print and complete, return by mail along with a copy of your health insurance card)   Medical Records Release Must be signed and returned to EPA for release of your medical records. (Print and complete, return to EPA)   New Patient Forms Use These for all new patients to Evansville Psychiatric Associates. (Print one of each and complete) Patient Information/Registration Agreement to Pay/Authorization for Insurance Payment Medical Records Release Patients' Rights and Responsibilities Statement HIPAA Acknowledgement   Dr. Kaplan New Patient Forms Child - up to 18 yrs of age and in high school. Physician Child Assessment Adult Self-Report Scale - V1.1 (one copy to be completed by each parent) Vanderbilt ADHD Diagnostice Parent Rating Scale Adult - 18 yrs (college-age) and above Physician Adult Assessment Adult Self-Report Scale PHQ-9 Mood Disorder Questionnaire