Consent for Services. I agree to participate in the Region 16 housing program and understand it is a program that consists of a combination of financial assistance and supportive services. I understand the ultimate goal of the program is for each participant to be able to maintain their own independent permanent housing in the future. I agree to actively participate in housing search, maintain monthly appointments, and will submit required program documentation. I understand that I may withdraw from the program at any time, and agree to meet with Case Manager to close my household’s case. I further understand, non-compliance with program requirements will result in termination from this program. Participant Name: __________________________________________ Date: __________ Participant Signature __________________________________________ Date: __________
Consent for Services. Thank you for reviewing this information and please feel free to discuss any of this information with me. My/Our signature(s) on this disclosure statement indicates I/We have read and understood the conditions of the consultation services outlined. I/We have had the opportunity to clarify any questions and agree to the terms described above before receiving services. I/We have been provided with a copy of this disclosure statement. Client Signature Date Client Signature Date Therapist Signature Date Client’s Initial’s Dear Client, As your therapist, I prefer not to discuss money or payment during session, unless payment is or becomes a therapeutic issue. Please use the following Credit Card Authorization document to indicate the form of payment you wish to use for any services rendered through this practice. In case of late cancellations and/no shows for scheduled sessions, you will be charged a $50 missed appointment fee. An additional $25 is assessed for returned checks. This form will be securely stored in your clinical file and may be updated upon request at any time.
Consent for Services. Client authorizes and approves ACM to contact current and past At-Fault Parties and their insurance carriers on Client’s behalf to gather information related to claims. To allow damage recovery specialists in-the-moment negotiation capability, once submitted to ACM, Client grants ACM the sole discretion and authority to settle Eligible Claims upon commercially reasonable terms consistent with reasonable industry standards. For the Term of this Agreement, Client grants ACM a limited power of attorney via a completed Authorized Representation Letter (Exhibit B) to act on its behalf for the purpose of signing and/or endorsing documents, drafts, and/or settlement checks related to Eligible Claims. Client also grants ACM access to loss run reports and related claim information from insurance companies/agents and claims staff and shall complete an Authorization to Obtain Loss Runs Letter (Exhibit C) for this purpose.
Consent for Services. School Health Center services may include: *mental health services (treatment, assessment, individual, and family counseling);
Consent for Services. I agree to participate in the Region 16 housing program and understand it is a program that consists of a combination of financial assistance and supportive services. I understand the ultimate goal of the program is for each participant to be able to maintain their own independent permanent housing in the future. I agree to actively participate in housing search, maintain monthly appointments, and will submit required program documentation. I understand that I may withdraw from the program at any time, and agree to meet with Case Manager to close my household’s case. I further understand, non-compliance with program requirements will result in termination from this program. Participant Name __________________________________________ Date: __________ Participant Signature __________________________________________ Date: ______________ I understand and agree to adhere to all the guidelines stated herein which have been fully discussed with me and agree to voluntarily sign this contract. I also agree to truthfully report any problems, changes, or concerns that occur during the length of involvement with the program. I further understand that my active participation in the program’s services allows the Case Manager to support my household’s ability to achieve housing stability.
Consent for Services. We are committed to providing you and your family with the best possible dental care. A clear understanding of our policies is important to a professional relationship. Please ask if you have any questions regarding these policies, our fees or your responsibilities. I grant permission to you or your assignee, to telephone me or my insurance company (if applicable) to discuss my statement or my treatment. I acknowledge that I have read the above policies, have had any questions fully answered, and agree to policy content. I give consent for routine dental procedures and diagnostic tests, including x-rays that are deemed necessary in the dentist’s professional judgment.
Consent for Services. Patient consents to healthcare by the Skin Cancer Center and its agents, as deemed necessary and appropriate under the circumstances by the Skin Cancer Center and its physicians. Said healthcare may include, but is not limited to, Mohs Mocrographic Surgery, routine medical care, routine nursing care, diagnostic procedures (including laboratory services), administration of medication(s) (including anesthetics) and all other services deemed necessary by Patient’s physician. Patient acknowledges that while at the Skin Cancer Center the Patient is under the control of their physician and that any Skin Cancer Center designee rendering service other than the physician is doing so at the direction of the physician. Patient understands that the Skin Cancer Center is a teaching facility affiliated with various teaching institutions, including Xxxxx State University and the Detroit Medical Center, and hereby consents to services being performed by students, residents or other medical and support staff of those facilities. Patient consents to the testing and disposal of specimens of his/her blood, urine and other bodily fluids, tissues and products. Patient understands that an HIV (human-immuno deficiency virus) test may be performed without Patient’s further consent if a Skin Cancer Center agent sustains a percutaneous, mucous membrane or open wound exposure to Patient’s bodily fluids.
Consent for Services. School Health Center services may include: *mental health services (treatment, assessment, individual, and family counseling); dental services at Northeast Health Center (preventative, restorative, and surgical); and *medical services, including primary care, treatment for illness and injuries, physical exams, vision/hearing screening, basic laboratory services and tests, medication administration, and education. Please check the box for the services you consent for your child to receive:
Consent for Services. On behalf of the Patient, consent is hereby given to the Facility, its independent contractors (see 2.b, below), medical staff, and employees to provide health care services to the Patient, to administer physician orders for the benefit of the Patient, and to provide all related care and services to the Patient while in the Facility, including but not limited to all routine and non-routine tests and studies ordered in the belief that they are medically necessary or appropriate for the Patient. See also, 2.a, below. It is understood that Facility services, medical care, and surgery are not exact sciences and that there is a risk of substantial and serious harm involved in such services, and such risk is accepted in the hope of obtaining beneficial results from such services. It is understood that the Patient and his/her legally authorized representatives have the right to ask questions and to receive answers to such questions about the Patient’s condition and the health care services. At this time, all such questions, if any, have been satisfactorily answered. No promises of any particular outcome or successful results have been made, it being understood and accepted that there is some uncertainty involved in the Facility and health care services for which consent is given.
Consent for Services. I am consenting to services from Club Spectrum ABA for the following:
