Client Consent for Treatment Sample Clauses

Client Consent for Treatment. The following information is provided to assist you in understanding policies and procedures at my office. Any questions or concerns you may have regarding the contents of this agreement should be discussed prior to signing it. By signing this agreement, you agree and acknowledge that any questions and/or concerns you have regarding the services or this agreement have been answered and resolved to your satisfaction.
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Client Consent for Treatment. I have read Xx.Xxxx’x OfWice Policy Statement and Client Agreement and understand its contents. I have asked any questions that I had about this statement, and about statements regarding fees, payment and collection policies. I consent to the use of a diagnosis and billing to my insurance company, and to the release of this Protected Health Information (PHI). I hereby authorize my insurance beneWits to be paid directly to Falcon Counseling LLC and I am Winancially responsible for any services not covered by my insurance carrier. I understand PHI is used to decide on the treatment approach, and may be used to coordinate treatment planning and care, including the sharing of information with other health care providers. By signing this form I agree to let my PHI be disclosed as related to my treatment, and with authorization to be disclosed to others. )The Notice of Privacy Practices explains in more detail your rights and how I can share your PHI. Please read this before signing the Consent Form). I consent to therapy under the terms described above with Xx. Xxxx, and understand that I have the right to terminate therapy at any time. My signature on this document attests that I have read the above information, that I consent to treatment, that I agree to the terms in this document, and that I have received a copy of this agreement. Furthermore, I understand after I have signed this consent, I can still revoke it (in writing) at anytime. This request will be honored from the time received, however, PHI already disclosed will not be affected. Client Signature (if client is between ages of 14-18 both client and parent / guardian must sign) Date Print Name Responsible Party Parent/Legal Guardian Date Print Name
Sample 1
Client Consent for Treatment. (initials) I have read this document and been given the opportunity to ask questions regarding this document and Healing Touch sessions.
Sample 1

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