Forms

Please visit the Patient Portal link to the right (or bottom of the page) to register, make appointments and access many forms online.  The forms are located in the My Health Section under the Medical Forms tab in you Patient Portal (please see below), as well as below.

Medicare & Medicaid/Quest Patients

Mindful Wellness Maui does not participate in the Medicare or Medicaid programs at this time.  Therefore, if you choose to work with us, you will need to pay the out-of-pocket rates listed on the Fees page.  To be seen for an initial consultation, Medicare & Medicaid requires that you review and sign the appropriate form below. We have pre-populated as much as we can for you.

Medicare Advanced Beneficiary Notice Form (click here)

HMSA Quest waiver (click here)

New Patient Forms

The new patient forms can be found in your Patient Portal, as well as below.  To save paper, please try to sign these forms electronically (please see the Initial Appointment Page for more information on how to Check In):

  • Assignment of Benefits (same as New Patient: Registration Form)
  • Privacy Notice (same as New Patient: Privacy Practices Form)

checkin forms

 

All of the forms can be found in the Patient Portal in the My Health Section under the Medical Forms tab. If you have already Checked In online and signed forms electronically the only two forms to review/sign/download are the first two listed below (Office Policies/Patient Agreement and Intake Form).

Signing Forms Online

 

Downloadable Forms

Intake Form 

Registration Form

Office Policies and Patient Agreement

Authorization to Release Medical Records

Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices

Notice of Privacy Practices