Forms

If you are using your health insurance and are a new client of Dr. Rutherford’s, please feel free to download the following forms as relevant, complete them as best you can, and bring them with you to the initial appointment. This will save us time at the first appointment.

Adult Forms:

Consent to evaluation–adult insurance

Collateral consent form – adult insurance (this form is NOT necessary/applicable if you are on MassHealth)

Adult HIPAA form

Release of records authorization form – adult

Child Forms: