Helpful Forms

If you are a new patient and would like to confirm if the provider accepts your insurance, please complete the following secure web form (link below) for Dr. Karina von Middendorf, MFT. You will be directed to a separate web page to complete and submit all your account set-up information securely per HIPAA guidelines. The information is sent directly to the Billing Manager, Victoria House at House Medical Billing Service LLC. You may also call her to submit your information by phone (530) 474-6094 . If you are completing the pdf version of the form (see Financial Agreement Form), you will have to email it back to Victoria at [email protected] or fax to (866) 849-0672.

Once your information form is received, Victoria will verify eligibility and benefits and confirm back to you and the provider via secure email with all details. This step is required in order to schedule your first appointment.

https://secureform.luxsci.com/forms/14261/6590/0Qv8/form.html

 

Client Intake Form

Patient Information and Financial Authorization Form (Hard Copy Version)

HIPPA Release Form

Note: To download Adobe Acrobat Reader for free, click here .