Forms

Referral Forms

•  Carls Center's Programs

•  Carls Center's Fall and Balance Clinic

 

Patient Registration and Intake Forms

•  Carls Center Registration Form

•  Audiology Clinic Intake Form - Adult

•  Audiology Clinic Intake Form - Child

•  Fall and Balance Intake Form

•  Physical Therapy Intake Form

•  Psychology Intake Form - Adult

•  Psychology Intake Form - Child

 

Medical Record Management Forms

•  HIPAA Information Acknowledgement Form

•  Protected Health Information Release Form

•  Request to Access Protected Health Information

•  Request to Restrict Information Release Form

•  Request for Accounting Disclosures

•  Photo Release Consent Form

•  Notification of Amendment to Protected Health Information

•  Request for Alternate Communications Form

Driving Study

The Department of Psychology at CMU is seeking adults for a study on attention and simulated driving. -- You must have a valid Michigan driver’s license and your own transportation. The experiment requires two one and a half hour sessions, and you will be paid $15.00 per hour for your participation. -- To volunteer or obtain more information, call Dr. Richard W. Backs at (989) 774-3234 or send an email to backs1rw@cmich.edu.

Find out more about the DEER Center