Patient Forms

Thank you for trusting Porter-Starke Services with your healthcare needs. Our knowledgeable and compassionate team is dedicated to providing the best service to our community. To begin treatment, please complete and sign the following forms. Our intake specialists will advise you on the best way to return these forms.

To view, print, or download, please click on the form title.

Welcome to Porter-Starke Services
Client Rights & Responsibilities
Notice of Privacy Practices

Client Instructions for Doxy.me Telemedicine Platform
Patient Portal How-to Instructions (for clients)

Authorization for Disclosure of Protected Health Information (Primary Care Physician)
Authorization for Disclosure of Protected Health Information (General)
Authorization for Disclosure of Protected Health Information for Insurance
Authorization to Receive Protected Health Information from Care Management Technologies (Private Data Company working with Indiana Medicaid)
Summary of Income
General Consent for Treatment & Financial Agreement
Authorization for Electronic Communication
Homeless Management Information System (HMIS) Notice of Privacy Practices (for clients involved in housing programs)

Formularios para pacientes nuevos en espanol (New Patient Forms in Spanish)

NICHQ Vanderbilt Assessment Scales (Used for Diagnosing ADHD)
NICHQ Vanderbilt Assessment Scale - PARENT Informant
NICHQ Vanderbilt Assessment Scale - TEACHER Informant

NICHQ Vanderbilt Assessment Follow-Up - PARENT Informant
NICHQ Vanderbilt Assessment Follow-Up - TEACHER Informant