Intake Process

In order to commence or continue psychiatric treatment, Dr. Cheney requires that all patients or parents/caregivers of minor patients consent to treatment, privacy policies, practice polices, HIPAA regulations, and financial terms.  

All forms are downloadable below or through Osmind and are designed to be filled out electronically. If you prefer, you may print the forms, fill them out manually, and return them. Once you have completed the forms, please save and email the completed forms along with your insurance information (see 4 & 5 below) to Dr. Cheney at kc@kathryncheneymd.com. 

1. The consent form outlines medical practice policies and privacy policies and grants Dr. Cheney consent to treat the patient. 

2. The Health Insurance Portability and Accountability Act (HIPAA) form is federally required to define with whom you would like to share your confidential medical information as well as these persons' contact information.

3. The credit card form is required for patient fees, and cancellation fees, as applicable, and will be saved in Osmind - or you may upload your credit card information directly to Osmind.

4. While Dr. Cheney is out of network for commercial insurances, she is happy to provide you with a superbill following payment.  It is preferred that all patients upload their medical insurance to Osmind and update this regularly should it change.

5. As it is not uncommon for medications to require additional authorization from insurance, it is recommended by Dr. Cheney that you upload your pharmacy insurance card  to Osmind as well.  This will save time should an authorization be necessary for Dr. Cheney to complete.

6. Fees will be explained and an estimate of treatment cost will be provided at the time of the consultation, as per the Good Faith Act. This approach ensures transparency and allows clients to make informed decisions regarding their treatment options. It is important to note that the final cost may vary based on specific circumstances related to each individual case.