EFFECTIVE DATE OF THIS NOTICE. This notice went into effect on September 20, 2013.
EFFECTIVE DATE OF THIS NOTICE. This notice went into effect on Jan. 30, 2013
EFFECTIVE DATE OF THIS NOTICE. This notice went into effect as of date indicated on the following signature page. ACKNOWLEDGEMENT OF RECEIPT OF HIPPA NOTICE OF PRIVACY PRACTICES Your signature below indicates that you have received, read and understand the information included in the HIPPA Notice of Privacy Practices. Signed Date Parent/Guardian Please Print and Sign Your Name Below (when applicable): Date AUTHORIZATION AND CONSENT FOR RELEASE AND DISCLOSURE OF CONFIDENTIAL INFORMATION I, , Print Name of Client Address Date of Birth authorize and give my consent to (name & license # of healthcare practitioner): , and/or the administrative and clinical staff of the above named practitioner to discuss all aspects of my medical, psychotherapy and/or psychiatric treatment without restriction or qualification with: Name/Title, Organization Address Phone/Fax Signature of Client Date Print Name of Client Credit Card Authorization Form THIS INFORMATION IS PRIVATE AND CONFIDENTIAL Name as it appears on credit card: Phone number: Billing address of credit card with zip code: Email address: Card (Choose One) Visa Master Card _Discover American Express Credit Card Number: Expiration Date: Month/Year CCV OR CID Code: _ All patients are required to have an active credit card on file. Payment is due at the time of service, or at the session following a "no show" defined as a cancellation with less than 24 hours notice. If you prefer to pay by cash or check, please do so at the time of service, or at the session following a "no show." If payment is not received at the time of service or at the next session following a "no show," we will wait fourteen (14) days for a check to be received by mail. After 14 days your credit card will be charged for any balance due. I hereby authorize this credit card to be used for payments for services rendered by . This authorization will remain in effect until the expiration date of the card or a written request to revoke the authorization is sent to us at: . (Address) Please advise us immediately if your card is lost and/or stolen. Card Holder Signature: _ Date: Policy Regarding Telephone, Text and Email Contact Between Scheduled Sessions As your therapists, we commit ourselves to supporting you working towards your best health and well- being. As such, we give you our fullest attention and personal presence at your regularly scheduled appointment to help you work towards the goals you wish to achieve. We understand though that there may be times between your regularl...
EFFECTIVE DATE OF THIS NOTICE. I acknowledge receipt of this notice on the date written below. Signature: Date: Date: Single/Married: Name: Address: Home Phone: Cell Phone: E-mail: Date of Birth: Occupation: Name of Spouse or Significant Other: Minor Children? If yes, names and ages: Referral Source: Are you currently working with another therapist? (If so, who?) Have you had any therapy experiences before? (If so, when?) Prior Mental Health Diagnosis: Are you on any medications at this time? If so, list them: Contact in case of emergency: ************************************************************************** DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM I MAY DISCUSS YOUR MEDICAL CONDITION? Yes/No IF YES, WHOM? NOTE: you may revoke or modify an authorization with regard to any family member or other individual but such revocation or modification must be in writing. ************************************************************************** What brings you here today?
EFFECTIVE DATE OF THIS NOTICE. This notice went into effect on Jan. 30, 2013 I acknowledge receipt of this notice Patient Signature: Date:_ Spouse Signature: Date: Legal Guardian Name: Date:_ Acknowledgement of Receipt of Notice of Privacy Practice I, , have received a copy of this Office's Notice of Privacy Practices. Patient name: Signature: Date: • It is your right to refuse to sign this document For Office Use Only: The reason that a standard acknowledgment (such as the above) of the receipt of the Notice of Privacy Practices was not obtained: Patient refused to sign. Communication barriers prohibited obtaining the acknowledgement. An emergency situation prevented this office from obtaining it.
EFFECTIVE DATE OF THIS NOTICE. This notice is effective on August 1, 2017.
EFFECTIVE DATE OF THIS NOTICE. This notice went into effect on April 14, 2003 I acknowledge receipt of this notice. Patient Name (Print): Date: Signature: Witness: XXXXX XXXXX, M.S. Licensed Professional Counselor CHILD INFORMATION QUESTIONAIRE Date Name: SS#: Age: Birthdate: Birthplace: Address : City: State & Zip Code: Home Phone #: Who do you live with? Relation: Child is: Natural Adopted Other: Natural Father: SS#: Address: Phone#: Father’s Employer: Birthdate: Natural Mother: SS#: Address: Phone#: Mother’s Employer: Birthdate: Close Friend or Relative: Step-Father: SS#: Address: Phone#: Step-Father’s Employer: Birthdate: Step-Mother: SS#: Address: Phone#: Step-Mother’s Employer: Birthdate: PLEASE COMPLETE THE FOLLOWING PAGE Insured’s Full Name: Insurance Co: Group #: Contract/Policy #: Person to contact in case of emergency: Phone #: Relation: Siblings Age Living at Home Have major changes of any kind occurred in your family in the last few years? (Moves, changes in family relationships, situation, friends, school) Yes: No: If yes briefly explain: Has there been any psychiatric/psychological counseling for client and/or anyone else in the family? Yes: No: If yes, Who: _ When: Where: Is the child taking medication? Yes: No: If yes, name of medication: Medication Allergies: Child’s Physician, Name: Address: Who referred you to our office? Briefly describe your reason for seeking counseling: XXXXX XXXXX, M.S. Licensed Professional Counselor National Certified Counselor 000 X. Xxxxxx Rd. Fairhope, AL 36532 251.928.2983 AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION I, , DOB: SS# xxxxxx authorize and request and release and/or receive confidential, psychological, psychiatric medical records and opinions resulting from my contact with them to for the purpose of Specified Information: I understand that all matters relating to alcohol or drug abuse patient records are considered privileged and confidential and are treated as such by this agency. Information regarding such matters cannot be given without consent of the patient. This is in compliance with Section 2/31 of Public Law 93-282, 42 CFD Part 2. Information relating to alcohol and/or drug abuse is not required to be disclosed, except by specific consent permitted by the Regulations. Further, I understand that pursuant to state law, reports and other information pertaining to diagnostic treatment or care of sexually transmitted diseases are to be confidential and are not subject to public inspection or admission into evidence ...
