Please complete the intake forms for your selected clinician before your appointment whenever possible. Each clinician has his or her own required forms, so please do not complete forms for the wrong clinician. If the forms are not completed in advance, please arrive 15 to 20 minutes early to complete them in the office. Paper copies are also available at the front desk.
Use this form to authorize Dr. Jackie Jiang & Associates, LLC to release, receive, or exchange confidential information, including treatment records, psychological evaluation reports, testing-related records, billing/administrative records, or collateral communication. Please complete all required sections, including the recipient, purpose, records requested, expiration date, and signature. Incomplete forms may delay processing.
drjackiejiangandassociates.com
1586 37th Avenue, Moline, IL; 910 w 35th street, davenport, ia