Master Form Links

Jotform URL Directory Click copy to share manually
Back to Alis HVA Master Director

Patient Pre-Intake

Initial data collection, demographics, and insurance verification.

Release of Information (ROI)

HIPAA compliant release and request of health/confidential records form.

Medication Refill

Dedicated request form for active patients needing prescription renewals.

FAST Screening

Functional Assessment Screening Tool questionnaire for clinical evaluation.

General Contact

Standard non-urgent communication form for general inquiries and referrals.

Rapid Mood Screener (RMS)

Clinical questionnaire used to assess depressive symptoms and bipolar disorder.

Tris Savings Card

External

Manufacturer copay assistance link for Dyanavel XR, Onyda XR, QuilliChew ER.

Tebra Clinical Forms Checklist

Single Source of Truth (SSOT) for New Patient Intake Dispatch

Patient Intake Tab → Send Forms

1. Profile & Payment

  • Basic Information
  • Demographics
  • Emergency Contact
  • Financial Information (DO NOT CHECK)
  • Additional Information
  • Credit Card Authorization Form Required

2. Medical Intake & Screeners

  • Medications & Allergies
  • Past Medical History
  • Family History
  • Social History
  • Surgical History
  • Hospitalizations/Procedures
  • Implantable Devices
  • OB/GYN History
  • PHQ-9 (Screener)
  • GAD-7 (Screener)

3. Custom Forms & Consents

  • [1-INTAKE 1] ALL - Disclosure & Consents
  • [1-INTAKE 2] ALL - Comm & Care Team
Conditional Intake
Required (Pick 1)
18+ Must Send:
[1-INTAKE 3] ADULT - Clinical
OR
<18 Must Send:
[1-INTAKE 3] PEDS (<18) - Clinical

Do Not Send: Stimulant or Benzodiazepine agreements to New Patients. Dispatched post-evaluation only.