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FORMS

Downloadable Application Forms

Adult Background Form
Authorization Form
Child Background Form
Contact Consent
Demographic Form for Insurance
HIPAA Release
Notice of Privacy Practices
Welcome Letter
CUXOS Form
Authorization Form - School
CUDOS
Client Rights and Responsibilities
Credit Card Explanation
Financial Agreement Form
Informed Consent
Patient Rights and Responsibilities
Card on File Authorization Form
Debbie Miles
Administrative Assistant
Nancy Brown
Administrative Assistant
Sherry West
Office Manager
Alexandria Putney
Billing Coordinator
Sheila Shell
Administrative Assistant
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 (937) 276-3356
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(937) 276-9514
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Copyright © 2023 Cordell Associates, LLC.
All Rights Reserved. Terms of Use. Privacy policy.
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