Effective Date, Restrictions, and Changes to Privacy Policy. This notice will go into effect on January 1, 2016.
Effective Date, Restrictions, and Changes to Privacy Policy. This notice goes into effect on April 15, 2003.
Effective Date, Restrictions, and Changes to Privacy Policy. The policies and procedures set forth in this notice went into effect on August 01, 2016.
Effective Date, Restrictions, and Changes to Privacy Policy. This notice will go into effect on January 1, 2019. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. We will provide you with a revised notice at your request, and we will advise you of changes directly if you are in treatment at the time they occur (you may request in writing that notices be sent by mail at any time during the course of therapy, and all subsequent notices will be sent to you). Do you file insurance?
Effective Date, Restrictions, and Changes to Privacy Policy. This notice with go into effect on July 1, 2009. I reserve the right to change the terms of this notice to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by either mail or at the office.
Effective Date, Restrictions, and Changes to Privacy Policy. This notice is updated and will go into effect September 1st, 2018 I have reviewed and requested a copy of HIPPA Privacy Policies if desired: Signature: Date: Witness: Date: PATIENT INFO NEEDED FOR BILLING FOR XXXXXXX X. TOWER, MA, LLP, CPC Patient Name: Date of Birth: Address: City, State, Zip: Phone Number: Email Address: If child or someone will pay for services other than client: Guarantor’s name: Address: Phone: Insurance information: Must have a copy of insurance card (front and back). Must have a copy of pre-authorization, if applicable. Policyholder’s name: Date of birth: Address/Phone: Relationship to patient: Policy #: Group #: I agree that Xxxxxxx X. Xxxxx, MA, LLP, Therabill/OfficeAlly, and support staff working with Xxxxxxx X. Xxxxx, MA, LLP are authorized to submit insurance claims and follow up on insurance payments on behalf of Xxxxxxx X. Xxxxx, MA, LLP, CPC. Circle, Yes or No May we phone, email, or send a text to you to schedule or confirm appointments? YES NO If yes, list cell phone number and cell phone carrier service provider(Sprint,Verizon, AT&T) May we email you billing statements? YES, email: NO May we leave a message on your answering machine at home or on your cell phone? YES NO If yes, list what number is okay to leave messages Patient Signature: Date: AUTHORIZATION FOR RELEASE OF INFORMATION FROM THE RECORD OF: *Note anyone else you would like to be able to speak with me about your care* NAME: DATE OF BIRTH: I hereby authorize: Xxxxxxx X. Xxxxx, MA, LLP, CPC 4829 East Beltline NE to release specific information from my record to / and receive referral information from: (Name, position, address) I understand that my continued or future treatment by or payment to Xxxxxxx X. Xxxxx, MA, LLP, CPC is not conditioned upon my providing or signing this authorization. The information to be released is all of the records specified by description and date, and may include information about drug/alcohol usage. EXCEPT: The information to be released is to be used ONLY for the following authorized purpose: Coordination of Care The authorization is effective for the following period of time: From To My authorization can be withdrawn upon my request or if any of the following occur: EVENT: CONDITION: I understand that I may withdraw this release at any time by notifying the agency holding my records. Signature: Date: Client or Legal Guardian / Parent of Minor Release Obtained by: Date:
Effective Date, Restrictions, and Changes to Privacy Policy. This notice went into effect on April 15, 2003. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by telephone or email contact. I have read the above information and voluntarily request counseling services at Restored Hearts Counseling, and I agree with these terms and conditions Signature Date Xxxx Xxxxx M.A., LAPC, LAMFT xxx.xxxxxxxxxxxxxxxxxxxxxxxx.xxx xxxx@xxxxxxxxxxxxxxxxxxxxxxxx.xxx 000-000-0000 COUNSELING AGREEMENT AND CANCELLATION POLICY PLEASE READ AND SIGN THE FOLLOWING COUNSELING AGREEMENT AND CANCELATION POLICY. IF THE CLIENT IS UNDER 18 YEARS OF AGE, THE AGREEMENT MUST BE SIGNED BY THEIR PARENT OR GUARDIAN. Counseling Agreement I understand that I am entering into a confidential therapeutic counseling relationship. I understand that I have the right to terminate this relationship upon due notice to my counselor. I also understand that all fees, as outlined on the separate attached and signed sheet, are due at the time services are rendered unless previous arrangements have been made. I understand that information concerning my counseling cannot be divulged to other parties without my prior written consent unless directed by Xxxxxxx Xxx. Other conditions of confidentiality will be discussed during the initial session.
Effective Date, Restrictions, and Changes to Privacy Policy. This notice will go into effect on April 16, 2003. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice by mail. Through your signature below, you acknowledge having received this Service Agreement, including information leading to your giving your Informed Consent to receive Assessment and Treatment Services. You also acknowledge receiving: • Information Regarding Psychological Testing Not Covered by Insurance Benefits • Vermont Professional Conduct For Psychologists Title 26, Chapter 55, Section 3016 • New Hampshire Code of Administrative Rules, Mhp 502.02, and • HIPAA Notice of Policies and Practices to Protect the Privacy of Your Health Information Your signature below indicates that you have received a copy of and read the attached Service Agreement, the Vermont Professional Conduct For Psychologists, Title 26, Vt. Statues Annotated, Chapter 55, Section 3016, the New Hampshire Code of Administrative Rules, Mhp 502.02 and the HIPAA Notice of Policies and Practices to Protect the Privacy of Your Health Information. Your signature indicates that you give your informed consent for Twin State Psychological Services to carry out these services and agree to reimburse Twin State Psychological Services for all services provided, including charges for appointments not kept when you do not give a 48 hour notice cancelling the appointment as specified on page 1 of this Service Agreement and costs for psychological testing services not covered by my insurance company as specified on page 2 of this Service Agreement. Your signature indicates that you give Twin State Psychological Services permission to process your credit card for services received. TYPE OF CARD: Visa Mastercard Other - Specify: Name On Card: CCV: ZIP: Credit Card #: Expiration Date: Signature of Patient or Legal Guardian Print Name of Patient (and Legal Guardian if appropriate) Date Note: Please keep pages 1 - 14 of this document for your records. We will keep this page (page 15) in your file at our office. If you would like a copy of page 15, please tell us and we will provide a copy for you.
Effective Date, Restrictions, and Changes to Privacy Policy. This notice went into effect on May 1, 2003. Health Insurance Portability and Accountability Act went into effect April 15, 2003. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice in a timely manner dependent on the reason for the revision. Changes in the PHI law, for example, would necessitate a revision. Xxxxxx Xxxxx Licensed Psychologist, LLC PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT Previously I received a copy of the Psychotherapist-Client Services Agreement and have read it, reviewed it and we have discussed all of my concerns. My signature below indicates that I agree with this agreement or I disagree with certain areas. Agree Disagree (Specify areas) Client Signature Date Print Name
Effective Date, Restrictions, and Changes to Privacy Policy. This notice will go into effect on April 14, 2003. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice when information is requested. I have read the General Office Policies and HIPAA Notice. I have no questions and I understand the document. I was given an opportunity to ask questions. An overview of my rights and responsibilities were provided to me verbally as well. Patient Name: Patient Signature: Date:
