New Patient Consent for Treatment and Agreement to Policies:  Guardian’s of all new patients are required to sign the consent for treatment and review and acknowledge our policies and procedures. When an established patients turns 18 years old, they need to sign these documents as well. Click HERE to review and sign these documents. These  documents include:

• Acknowledgement & Authorization: It includes consent to receive mental health care from BanCAPs, allowing banCAPs to bill directly to your insurance company on your behalf for services rendered at BanCAPs, and accepting financial responsibility of services not paid by your insurance. 
• Consent for Financial Policy: It includes understanding and consenting to our billing process and understanding your financial responsibilities related to services rendered at BanCAPs. 
• Notice of Privacy Practices: This notice describes how medical information about the patient is stored and protected, how it may be used and disclosed and how you can get access to this information. 
• Consent for Patient Communication policy: It includes understanding and consenting to our communication policy. 
• Consent for Telemedicine services: We request all patients to read and sign this consent even if you do not intend to receive Telemedicine services as Telehealth visit might be needed in case a prompt visit is needed for any emergencies or for a consultation with Dr. Bansal as Dr. Bansal sees patients only via Telehealth. 

Authorization to communicate with family members (for Minors): If patient is younger than 18 years of age and/or has a guardian, this form needs to be filled out to document name of guardians and also to allow additional family members to obtain information about patient’s treatment. Click HERE to complete this form. 

Authorization to communicate with family members (for Adult patients): If patient is 18 years or older and wants to allow a family members (including parents) to obtain information about the treatment, patient needs to complete and sign this form by clicking HERE. 

Authorization to communicate with your PCP: This document authorizes BanCAPs and its agents/employees to RELEASE and OBTAIN information and copies of records pertaining to a patient’s medical/psychiatric treatment to/from the patient’s Pediatrician or Primary Care Provider. Click HERE to complete this document. 

New Patient Intake Medical & Psych Hx: This is a questionnaire to obtain patient’s psychiatry, medical, family, educational and social history. Click HERE to complete this document. Do not fill out this form if you just turned 18 and are already an established patient at BanCAPs. 

New Patient Intake Sx. Checklist: It includes a series of questions designed by Dr. Bansal to ensure completion of a Comprehensive Psychiatry Assessment. Click HERE to complete this document. Do not fill out this form if you just turned 18 and are already an established patient at BanCAPs. 

Copy of your insurance card & Guardian’s ID: We also need a picture of the front and back of your insurance card and picture of patient’s Guardian’s ID which you will be requested to send via a secure message.