Common use of Complaints & Disputes Clause in Contracts

Complaints & Disputes. Please bear in mind that a complaint is a very serious action and should be made if and when you believe professional misconduct has taken place. It is important to me that we resolve difficulties together should a problem arise. Part of therapy/treatment is learning new methods to communicate effectively. Before making your decision to report a health care provider, keep in mind that many common complaints such as scheduling problems, personality conflicts, or disputes over bills or insurance are usually not within the Department or board’s legal authority to take action. Reports involving fees or insurance claims are only investigated if there appears to be fraud involved. If you believe that I have caused you harm or have violated your rights, you are asked and encouraged to contact me so that we may discuss the situation. I can be reached by telephone at 000-000-0000 or a written complaint may be mailed to me at 000 Xxxx Xxx X., Xxxxx 000, Xxxxx Xxxx, XX 00000. If it is not possible to resolve an issue or a complaint in a way that you find satisfactory, a formal complaint can be made with the Washington State Department of Health at the address below. Washington State Department of Health Professions Quality Assurance P.O. Box 47865, Olympia, WA 98504-7865 Certainly, you have the right to accept, refuse or discontinue therapy or to ask for a referral to another therapist at any time. If you choose to do this, please discuss your decision with me before ending therapy. This will allow us a valuable opportunity to discuss the reasons for your decision and will provide a sense of a more thoughtful ending. I have read Xxxx Xxxxx Counseling Informed Consent and Practice Policies Patient Signature Date

Complaints & Disputes. Please bear in mind that a complaint is a very serious action and should be made if and when you believe professional misconduct has taken place. It is important to me that we resolve difficulties together should a problem arise. Part of therapy/treatment is learning new methods to communicate effectively. Before making your decision to report a health care provider, keep in mind that many common complaints such as scheduling problems, personality conflicts, or disputes over bills or insurance are usually not within the Department or board’s legal authority to take action. Reports involving fees or insurance claims are only investigated if there appears to be fraud involved. If you believe that I have caused you harm or have violated your rights, you are asked and encouraged to contact me so that we may discuss the situation. I can be reached by telephone at 000-000-0000 425-­‐462-­‐8558 or a written complaint complain may be mailed to me at 000 Xxxx 0000 000xx Xxx X.XX, Xxxxx 000, Xxxxx Xxxx000 Xxxxxxxx, XX 00000. If you believe that it is not possible to resolve an issue or a complaint with me individually, you are encouraged to contact Xxxxx X. Xxxxxxx, CDP, LMHC (the clinical director of Eastside Center for Family) by telephone at 425-­‐462-­‐8558 to discuss the matter further. If it is not possible to resolve an issue or a complaint in a way that you find satisfactory, a formal complaint can be made with the Washington State Department of Health at the address below. Washington State Department of Health Health Professions Quality Assurance P.O. Box 47865, Olympia, 47865 Olympia WA 98504-7865 Certainly, you have the right to accept, refuse or discontinue therapy or to ask for a referral to another therapist at any time. If you choose to do this, please discuss your decision with me before ending therapy. This will allow us a valuable opportunity to discuss the reasons for your decision and will provide a sense of a more thoughtful ending. 98504-­‐7865 I have read Xxxx Xxxxx Counseling Informed Consent Xxxxxxx Xxxxxxx, LMHC, CDPT disclosure statement and Practice Policies Patient client agreement: Patient’s Signature Date Patient’s Name Patient’s Date of Birth Parent or Guardian’s Signature (if patient is under 13 y.o.a.) Date

Complaints & Disputes. Please bear in mind that a complaint is a very serious action and should be made if and when you believe professional misconduct has taken place. It is important to me that we resolve difficulties together should a problem arise. Part of therapy/treatment is learning new methods to communicate effectively. Before making your decision to report a health care provider, keep in mind that many common complaints such as scheduling problems, personality conflicts, or disputes over bills or insurance are usually not within the Department or board’s legal authority to take action. Reports involving fees or insurance claims are only investigated if there appears to be fraud involved. If you believe that I have caused you harm or have violated your rights, you are asked and encouraged to contact me so that we may discuss the situation. I can be reached by telephone at 000-000-0000 425-­‐462-­‐8558 or a written complaint complain may be mailed to me at 000 Xxxx 0000 000xx Xxx X.XX, Xxxxx 000, Xxxxx Xxxx000 Xxxxxxxx, XX 00000. If you believe that it is not possible to resolve an issue or a complaint with me individually, you are encouraged to schedule an appointment with Xxxxx Xxxxxx, LMHC and me to discuss the matter further. If it is not possible to resolve an issue or a complaint in a way that you find satisfactory, a formal complaint can be made with the Washington State Department of Health at the address below. Washington State Department of Health Health Professions Quality Assurance P.O. Box 47865, Olympia, 47865 Olympia WA 98504-7865 Certainly, you have the right to accept, refuse or discontinue therapy or to ask for a referral to another therapist at any time. If you choose to do this, please discuss your decision with me before ending therapy. This will allow us a valuable opportunity to discuss the reasons for your decision and will provide a sense of a more thoughtful ending. 98504-­‐7865 I have read Xxxx Xxxxx Counseling Informed Consent Xxxxxxx’x disclosure statement and Practice Policies client agreement: Patient Signature Date