Click on any of the Headings listed below to access our forms.

Consent Form

State law requires us to have a Consent Form signed by the person with the legal authority to request medical services on behalf of the Resident.  In most cases, this person is the Resident herself.  However, Guardians should sign the Consent Form when applicable.  Please note that a signature is required by law; we cannot accept verbal consent for services.

Medical Necessity Form

To ensure our Providers understand the reason for the referral, please complete the Medical Necessity form.  The Social Worker should identify the Resident’s presenting problems, and the attending physician (or NP/PA) should sign the form to issue a medical order for psych services.  In cases where the referral must be expedited, we can accept a handwritten medical order as a substitute for the Medical Necessity Form.

Expert Evaluation Request Form

Please use this form to request Guardianship Evaluations (aka, “Expert Evaluations”).

Escalation of Psychiatric Care Request Form

If a 360care Psychiatry Patient needs a med adjustment before his/her next scheduled psychiatric visit, complete this form and give it to your 360care Psychiatry NP or PA when she is on-site.

Behavioral Description of Services

FPay Agreement – 360care

FSA Electronic Access Addendum

Notice of Privacy Practices

Online Charts 360care

Completed forms can be emailed to us at: [email protected].  If you don’t have a scanner, you can fax forms to us at
(844) PSYCH-FX.  That’s (844) 779-2439.