The forms you will need are posted below for your convenience.
Please complete and submit online the appropriate forms. Upload insurance card and photo ID using the Secure Upload Documents to 1AllianceCPS link below.
You can also complete, print and sign the appropriate forms. Remember to bring them to your appointment or scan signed forms and upload using the link below Secure Upload Documents to 1AllianceCPS or fax signed forms to 866.907.3948.
Thank You!
Client Required Registration Forms:
| Client Registration – Client Information – Client Services Agreement and Consent for Treatment – HIPAA Notice Form* | Required for all clients before your first visit AND every January to update client information, HIPAA, and policies from 1 Alliance CPS as we do review and update our forms and policies at least every January. | Online Form | |
| Personal Disclosure for North Carolina Clients | Required for all new clients from North Carolina before your first visit to 1AllianceCPS | Online Form – Lisa Smith – Heather McMahon | PDF Lisa Smith PDF Heather McMahon |
| Credit Card Authorization Form | Authorize 1AllianceCPS to charge my credit card for agreed upon services. | Online Form | |
| Secure Upload Documents to 1AllianceCPS | Photo ID and Insurance Card (front and back) required for all new clients before your first visit AND if there is any change in your insurance and / or photo ID such as new insurance benefit year, new insurance carrier, name change, address change, or gender marker. | Online Form |
Client Optional Forms:
| Release of Information Optional (Speak with your 1Alliance Provider prior to completing) | Complete this form if there are others (doctors, other providers) you wish us to share or receive information with regarding your visits. | Online Form | |
| Prescription Refill Form Medication management patients only | Complete this form to request prescription refills from your prescribing provider. | Online Form |
EAP (Employee Assistance Program) Forms:
Please only complete the forms of the EAP company you are using. If your EAP is not listed, your company may not require a form. Please check with the office if you have further questions.
| EAP Statement of Understanding and Client forms Optional (Speak with your 1Alliance Provider prior to completing) | Magellan EAP Statement of Understanding | ||
| Magellan Client Information Form | |||
| Health Advocate Statement of Understanding | |||
| Kepro Statement of Understanding | |||
| New Directions Statement of Understanding | |||
| Mutual of Omaha Statement of Understanding | |||
| Workplace Solutions Statement of Understanding | |||
| Humana EAP Lifesych Statement of Understanding | |||
| BHS Statement of Understanding |
Self Assessment Forms:
(Speak with your 1Alliance Provider prior to completing)
| Adult ADHD Self-Report Scale (ASRS v 1.1) Symptom Checklist | Online Form | ||
| Alcohol Disorders Identification Test | Online Form | ||
| Patient Health Questionnaire (PHQ-9) | Online Form | ||
| Anxiety Self Assessment (GAD7) | Online Form |
If you have any questions regarding these forms please contact us at 678.310.6631 in GA, 336.567.3001 in NC, or email us at info@1alliancecps.com