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.
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. This notice will go into effect on January 1, 2016.
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).
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.
Effective Date, Restrictions, and Changes to Privacy Policy. This notice went into effect on August 1, 2004. I reserve the right to change
Effective Date, Restrictions, and Changes to Privacy Policy. Your clinician reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that your clinician maintains. Your clinician will provide you with a revised notice by the time of your next appointment after the revisions are made, or by U.S. mail in the event that you are not available for receipt of the revisions in office.
Effective Date, Restrictions, and Changes to Privacy Policy. This notice will go into effect on April 14, 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 at your next visit or by mail. Client Name (Please Print) Client Signature Date If Applicable: Parent/Legal Guardian’s Name (Please Print) Parent/Legal Guardian’s Signature Date Xx. Xxxx Xxxxxxx Date Licensed Professional Counselor-Supervisor Registered Play Therapist-Supervisor NAME: CHILD’S NAME: ADDRESS: CITY/ZIP: PHONE: CAN MESSAGES BE LEFT? Y/N WORK PHONE: CAN MESSAGES BE LEFT? Y/N CELL PHONE: CAN MESSAGES BE LEFT? Y/N EMAIL ADDRESS: CAN MESSAGES BE LEFT? Y/N LIST OF CURRENT MEDICATIONS: Client’s Full Name: Client’s Date of Birth (MM/DD/YY): Client’s Address/City/Zip Code (as given to insurance company): Client’s Relationship to the insured: Self Spouse Child Other Client’s Social Security #: Client’s Driver’s License # and State: ************************************************************************************* (This is information about who carries the insurance) Insured’s Full Name: Insured’s ID Number: Insured’s Address/City/Zip (If different from the client’s): Insured’s Phone Number (If different from the client’s): ( ) Insured’s Social Security # Insured’s Driver’s License # Insured’s Policy Group or FECA Number: Insured’s Date of Birth (MM/DD/YY): Insured’s Employer’s Name or School Name: Insurance Plan Name or Program Name: Authorization # (must have prior to your first appointment): Number of sessions approved: Client’s or authorized person’s signature: I authorize the release of any medical or other information necessary to process this claim. I also request payment of medical benefits to the supplier of services (Xx. Xxxx Xxxxxxx, M.Ed., LPC-S, RPT-S) Signed: Date: Thank you so much for choosing the services that I provide. This document is designed to inform you about what you can expect from me regarding confidentiality, emergencies, and several other details regarding your treatment as it pertains to Technology-Assisted Services. Technology-Assisted Services is defined as follows:
Effective Date, Restrictions, and Changes to Privacy Policy. This notice is updated and will go into effect September 1st, 2018
