WS Documentation Self-Service Request Form

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WS Documentation & Communication Fees Policy* This field is required.Please Be Aware That Some Forms of Documentation Requests Will Incur A Fee. The WS Fee Schedule is on the WS website. Submitting this request is both an acknowledgment of these fees and permission to accept fees associated with this request. WS will make every effort to attend to your request as soon as possible. Please be aware that WS will not accept a request for clinical documentation from anyone other than the client himself/herself or a client's parent or guardian. The WS estimated turnaround time for documentation requests is approximately 7-10 business days. In the event, clinical documentation is needed sooner than 7-10 business days AND the WS staff are able to expedite a request additional fees will apply. WS will review and consider all requests to determine if the request is appropriate to complete. WS does NOT accept subpoenas via email, fax, mail, or online form. WS does not participate in cases or instances where interaction with the legal system is requested or required.
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The Client is ....* This field is required.
an Adult (18+)
a Minor (13-17 Years Old)
an Adult Under Guardianship
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Client First & Last Name* This field is required.Please enter the client's First & Last Name below
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Client's Initials* This field is required.Initials of the CURRENT CLIENT. Please enter the client's initials below.
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Client Date of Birth * This field is required.Please enter the client's date of birth in the following format XX/XX/XXXX.
Date
Year
Month
Day
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Client Phone Number* This field is required.Please enter the client's phone number in the following format (XXX)XXX-XXX
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Client Email* This field is required.Please enter the client's email address below.
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Client HIPAA Verification of Identity Compliance Requirement* This field is required.Please take a picture of the valid state issued identification of the client or the client's parent for HIPAA verification of identity compliance. For minor's who do not have a current state issued ID you can use a school ID. WS cannot accept this request without HIPAA verification of identity.
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Max. file size: 10.6MB
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WS Clinician - Who is your WS therapist?* This field is required.Please type in the name of your WS therapist?
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Client's Parent First & Last Name
First Name
Last Name
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Client's Parent Phone Number
Area Code
Phone Number
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Client's Parent Email
example@example.com
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Client's Parent Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Client's Parent HIPAA Verification of Identity Compliance RequirementPlease take a picture of the valid state issued identification of the client or the client's parent for HIPAA verification of identity compliance. WS cannot accept this request without HIPAA verification of identity.
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Select files to upload
Max. file size: 10.6MB
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What Type of Documentation Would You Like To Request?* This field is required.WS Sends an emailed receipt each time the client's credit card on file is charged. WS also sends a patient statement at the end of each month to all accounts with an open balance after insurance claims adjudication is complete. Requests for additional receipts will incur a fee.
Account Information / Billing Information
Clinical Documentation / Clinical Letter / Clinical Summary for Treatment
Educational Advocacy
Insurance HSA Letter
Out of Network Insurance Superbill (Not Available for Sliding Scale Fee)
Receipt for a Specific Date of Service
Receipt (General)
School / Work Excuse
Other
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Please Explain The Type of Documentation You Are Requesting:* This field is required.Please be aware that Wellness Solutions, LLC will NOT accept or process a request for documentation from anyone other than the adult client or the parents of a minor client. If you are representing a third party we will not accept this request.
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What is this Documentation Request For? How will this Documentation Request Be Used?* This field is required.
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Who Do You Intent To Share This Information With? * This field is required.
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What is your REQUESTED due date for this documentation? The approximate turnaround time for WS documentation requests is 7-10 business days. WS will make every effort to attend to your request as soon as possible. In the event, clinical documentation is needed sooner than 7-10 business days AND the WS staff are able to expedite a request additional fees will apply. WS will review and consider all requests to determine if the request is appropriate and valid to complete. * This field is required.
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What Format Would You Like To Receive This Documentation Request? * This field is required.
Email
Fax
Patient Portal
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Signature* This field is required.With my signature below I give WS permission to use the contact information provided in order to begin the appointment scheduling process. I understand that the submission of an appointment request is not a guarantee of an appointment. Please sign the below request.
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