top of page

American Health Network,

Part of Optum

122 Columbus Road,

Fredericktown OH 43019

P: 740.694.1261 F: 740.694.7145

Please reference below for printable forms and instructions to improve your experience

New Patient Form

Counseling Intake Form

Patient Data Sheet

Patient Financial Policies

Patient Authorization for Disclosure

Counseling Child Informed Consent

Counseling Adult Informed Consent

Counseling Patient Disclosure

Annual Physical Form

Counseling Fee Agreement

Release of Medical Records

Patient Portal (Email) Instructions

family focus. quality care. convenience.

bottom of page