Client Consent. My signature below indicates that I reviewed this document, agree to the policies, and authorize the services. I accept financial responsibility for payment of services received, and for payment of late cancellations. If I use insurance to pay all or a portion of the charges, I hereby authorize the release of information necessary to process insurance claims filed on my behalf. I acknowledge that I am financial and legally responsible for the full payment of charges for services received in the event my health insurance policy does not cover my claim. I am 18 years of age or older or I have legal custody of this minor child(xxx). Client Name (Print): Client Signature: Date: Custodial Parent or Guardian Signature: Date: Therapist Signature: Date: Notice of Privacy Practices 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Client Consent. I/We understand and consent to the above terms and I hereby authorise the transfer of information, as described above on a confidential basis when warranted between such third parties. I/We agree that the Client Agreement will come into effect from the date of issue. This agreement is governed by English Law. This is our standard client agreement upon which we intend to rely. For your own benefit and protection you should read these terms carefully before signing them. If you do not understand any point please ask for further information. I/We the below mentioned client have read and understand the above Client Agreement and sign my/our acceptance below. I/We understand that the terms will come into force upon our acceptance. Client Signature 1: Date: Print Name: Client Signature 2: Date:
Client Consent. My signature below indicates that I reviewed this document, agree to the policies, and authorize the services. I accept financial responsibility for payment of services received, and for payment of late cancellation fees. If I use insurance to pay all or a portion of the charges, I hereby authorize the release of information necessary to process insurance claims filed on my behalf. I acknowledge that I am financial and legally responsible for the full payment of charges for services received in the event my health insurance policy does not cover my claim. I am 18 years of age or older or I have legal custody of this minor child(xxx). Client Name (Print): Client Signature: Date: Custodial Parent or Guardian Signature: Date: Therapist Signature: Date: 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Appointment Reminders Care and Counseling offers the option to receive an appointment reminder the day prior to your scheduled appointment by email (up to 2 email addresses) and/or by phone (only 1 phone number permitted). If you choose the reminder by phone, you have the option of a text message or a computer-generated voice message. PHONE REMINDER (only one type of phone reminder can be provided): Text Message: I authorize Care and Counseling to send text message appointment reminders to me on my provided cell phone number. Text message charges from my cell phone provider may apply. Example of text message: “Do not reply-reminder-You have an appointment MON 01/11 at 4:00 PM – If you have any questions please call us at (000) 000-0000 – Name of Counselor Cell phone number to send text messages to: ( ) - Automated Voice Messages: I authorize Care and Counseling to send computer generated voice phone message appointment reminders to me on my provided phone number.
Client Consent. The Client hereby grants to the Department of Waste Management and its employees, the permission to enter upon and use the venue for the purpose of delivery and removal of litter bins.
Client Consent. 27 Section 6.2 Conduct of Business................................................................ 27 Section 6.3 Preservation of Business and Assets................................................ 28 Section 6.4 Standstill......................................................................... 29 Section 6.5
Client Consent. Client hereby grants Babette’s and its employees, to enter the Property for the purpose of providing a design consultation.
Client Consent. This is our standard client agreement upon which we intend to rely. For your own benefit and protection you should read these terms carefully before signing them. If you do not understand any point please ask us for further information. Please tick this box if you do not wish for us, or any company associated with us, to contact you for marketing purposes by e-mail, telephone, post or SMS: I/We confirm that I/we agree to the adviser being remunerated on the basis we have chosen below: £
Client Consent a. As soon as practicable after the date hereof, each of the Xxxxxxxxx Entities shall notify each of its clients (including the participants in each Existing Fund) of the transactions contemplated hereby and by the other Transaction Documents. That notice shall be in the form of Exhibit 6.1(a) hereto.
Client Consent. End Users may not enter a Client’s personal information into the GA Comparable Database or share such information with third parties without informed written consent. The Client has the right to revoke consent at any time for any reason. If the client wishes to revoke their consent for their information being entered into the GA Comparable Database from the date of revocation moving forward, then the GA HMIS Client Consent Revocation form should be completed, signed, dated and inserted into the client file. Client Intake: Client Intake includes entering new client data or updating information for a client that is already in the G A Comparable Database. Any client intake should start with a thorough Client search to make sure the Client is not already in the GA Comparable Database and reduce the number of duplicates. All efforts should be taken to ensure duplicate records are not created within the GA Comparable Database. The GA Comparable Database is a closed system, meaning that End Users cannot search for Clients at other Agencies. However, End Users should do a client search within their own agency to avoid duplication. For further instructions on how to conduct a client search, refer to the ClientTrack User Guide. Each agency should enter and/or update the Universal Data Elements for all household members and Program Specific Data Elements (where required) at intake. Detailed information about these data elements can be found below. Ideally, an agency would input the information into the GA Comparable Database during intake, however when paper intake forms are necessary please use the Intake and Project Update forms that have been provided. These forms can also be accessed from theHMIS website: xxxx://xxx.xxx.xx.xxx/housing/specialneeds/programs/hmis.asp. Care should be taken to make sure that all of a Client’s information is updated (such as housing status, marital status, household, etc.) at intake if they have an existing record in the system.
Client Consent. In Writing… The Financial Ombudsman Service, Xxxxxxxx Xxxxx, Xxxxxx X00 0XX By phone… 0000 000 0000 By email… xxxxxxxxx.xxxx@financial- xxxxxxxxx.xxx.xx
