Forms and Information
Welcome to Two Rivers Neuropsychology.
Referring providers: please use the referral form and fax it to 515-335-0247.
Referral information includes a two-pager on how to discuss neuropsychological testing with your patient, if needed.
New patient forms are available through the drop down links to the right.
Please do not hesitate to call us at 515-220-2747 or email at info@tworiversneuropsych.com if you have any questions about paperwork for your first visit or about your records.
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Permission to release and/ or obtain information.
Download Release of Information Form here. -
Basic demographic and billing information, authorization and consent form.
Download Patient Registration Form here. -
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Notice of policies and practices to protect the privacy of your health information. Download our policy here.
“I'm lucky to have gotten to work so closely with you over my postdoc year. I think of you often as I am working on reports and conceptualizing my cases. Your guidance was very impactful for me..”
— C.R.