Secure Document and Records Submission Form

1

Patient's Name* This field is required.

First Name

Last Name

2

Patient's Date of Birth* This field is required.

Date

3

Submitter InformationIf you are submitting information on behalf of yourself, please type 'self' in the first box.

4

Purpose of Submission* This field is required.Please briefly describe the purpose of the submission.

5

HIPAA Compliant Secure File Upload* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

6

Attestation: I am sending these records for an individual who is already an established patient at NW ADHD Treatment Center. I understand that any records submitted for an individual who is not yet an established patient will not be retained and will be securely destroyed. I understand that anyone seeking services at Northwest ADHD Treatment Center must have their provider submit a referral form.* This field is required.

I agree and understand the above. I am submitting these records on behalf of an individual who is an established patient at Northwest ADHD Treatment Center.