Please complete these forms in their entirety, sign all necessary signature lines and submit electronically. A member of the Intake Department will contact you to discuss scheduling an appointment.
Please complete this form if you would like CBHA to disclose your personal health information with anyone other than yourself or to obtain records from your previous providers.
Please complete this form, sign the necessary signature line and submit electronically. Email photos of the front and back of your insurance card to billing@cbhapc.com.
If you are a client who is interested in TelePsych services, please complete this form.
Please read and review the full Suboxone Contract, then sign and submit this form if you are seeking to enroll into the Suboxone Program.
Upon finishing any of the necessary forms below, please fax or email them following the provided instructions. If the instructions do not include an email or fax, please send the completed forms to supportstaff@cbhapc.com.
Attached you will find the most up-to-date office policies regarding; canceling or rescheduling of appointments, NO SHOW/LATE CANCELLATION policy, medication refills, paperwork/forms or medical records requests.
Attached you will find the most up-to-date financial policies regarding; acceptable payment methods, service/administrative fees, No Show/Late Cancellation fees and Collection fees.
If you are seeking to become a new client of CBHA please complete this form and fax it to (860) 823-1170, drop if off at any CBHA location or email it to intake@cbhapc.com. A member of the Intake Department will contact you within 24-48 hrs of receipt.
If you are a provider and wish to refer your client for out-pt treatment from a higher level of care, please complete this form and fax it to (860) 823-1170. A member of the Intake Department will contact you within 24-48 hours of receipt.
Please read and review the full Suboxone Contract, then sign and submit this form if you are seeking to enroll into the Suboxone Program.
If you are a provider and wish to refer your client for Spravato, please complete this form and fax it to (860) 823-1170 or email intake@cbhapc.com The Spravato Coordinator will contact you within 24-48 hours of receipt.
If you are a provider and wish to refer your client for out-pt substance abuse treatment from a higher level of care, please complete this form and fax it to (860) 823-1170. A member of the Intake Department will contact you within 24-48 hours of receipt.
For clients who are required to seek therapy and see a provider outside of CBHA, this form is required to show proof of on-going treatment.
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