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.
Appears in 5 contracts
Samples: Consent for Services, Health History –, Consent for Services
