PATIENT SERVICES AGREEMENT Sample Clauses

PATIENT SERVICES AGREEMENT. Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purposes of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is given with this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us.
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PATIENT SERVICES AGREEMENT. WELCOME. This document contains important information regarding this office’s professional services and business policies. It accompanies the information you were given about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that protects privacy and patient rights with regard to the use and disclosure of Protected Health Information (PHI). HIPAA requires that this office provide you with a Notice of Policies and Practices to Protect the Privacy of Your Health Information (hereinafter “the Notice”) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which has been provided to you separately, explains HIPAA and its applications to your PHI in greater detail. The law requires that this office obtain your signature acknowledging that you have been provided with this information. Although these documents are long and sometimes complex, it is important that you read them carefully before signing. You can discuss any questions you have about the procedure at any time with your counselor. When you sign this document, it represents an agreement between you and The Talking Place, Child and Adolescent Counseling, LLC (hereinafter “this office”). You may revoke this Agreement in writing at any time. That revocation will be binding on this office unless this office has taken action with reliance on it; or if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
Sample 1Sample 2See All (4)
PATIENT SERVICES AGREEMENT. Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless: a) I have taken action in reliance on it; b) there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; c) you have not satisfied any financial obligations that you have incurred. Psychological Services Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.
Sample 1See All (4)
PATIENT SERVICES AGREEMENT. Welcome to my practice. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA). This federal law provides new privacy protections and new patient rights regarding the use and disclosure of your Protected Health Information (PHI). HIPAA requires that I provide you with a Notice of Privacy Practices accompanying this document. The law requires that I obtain your signature acknowledging that I have provided you with this information and that you agree/consent to let me use your information as specified in the Notice. Although these documents are long and sometimes complex, it is essential that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have acted in reliance on it, if there are obligations imposed on me by your health insurer to process or substantiate claims made under your policy, or if you have not satisfied any financial obligations you have incurred.
Sample 1Sample 2
PATIENT SERVICES AGREEMENT. Welcome. This document contains important information about my professional services and business policies. Although this document is long, it is very important that you read it carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us.
Sample 1Sample 2
PATIENT SERVICES AGREEMENT. Welcome to my practice. This Agreement contains important information about my professional services and business policies. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. In addition, The Health Insurance Portability and Accountability Act (HIPAA), a new federal law, requires that I provide you with a Notice of Privacy Practices and that I obtain your signature acknowledging that I have provided you with this information. Those Privacy Practices appear at the end of this document and constitute a part of this agreement. You will receive a copy to keep at the end of our first session.
Sample 1
PATIENT SERVICES AGREEMENT. My signature below indicates that I have read the information in the Psychotherapist-Patient Services Agreement document and agree to abide by its terms during our professional relationship. Name of patient (printed)
Sample 1
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PATIENT SERVICES AGREEMENT. Welcome. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI). PHI is used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is separate from this Agreement, explains HIPAA and its application to your PHI in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this Notice. Although this document and the Notice are long, it is very important that you read them carefully. We can discuss any questions you have. When you sign this document, it will also represent an agreement between us.
Sample 1

Related to PATIENT SERVICES AGREEMENT

  • Services Agreement “Services Agreement” shall mean any present or future agreements, either written or oral, between Covered Entity and Business Associate under which Business Associate provides services to Covered Entity which involve the use or disclosure of Protected Health Information. The Services Agreement is amended by and incorporates the terms of this BA Agreement.

  • Project Management Services Contractor shall provide business analysis and project management services necessary to ensure technical projects successfully meet the objectives for which they were undertaken. Following are characteristics of this Service:

  • Inpatient Services Hospital This plan covers services provided while inpatient in a general or specialty hospital including, but not limited to the following: • anesthesia; • diagnostic tests and lab services; • dialysis; • drugs; • intensive care/coronary care; • nursing care; • physical, occupational, speech and respiratory therapies; • physician’s services while hospitalized; • radiation therapy; • surgery related services; and • room and board. Notify us if you are admitted from the emergency room to a hospital that is not in our network. Our Customer Service Department can assist you with any questions you may have about your coverage. Rehabilitation Facility This plan covers rehabilitation services received in a general hospital or specialty hospital. Coverage is limited to the number of days shown in the Summary of Medical Benefits.

  • INDIVIDUAL SERVICES AGREEMENT This contract shall include an Individual Services Agreement (ISA) developed for each LEA pupil to whom CONTRACTOR is to provide special education and/or related services. An ISA shall only be issued for LEA pupils enrolled with the approval of the LEA pursuant to Education Code section 56366 (a)(2)(A). ISAs are void upon termination or expiration of the Master Contract. In the event that this Master Contract expires or terminates, CONTRACTOR and the LEA shall continue to be bound to all of the terms and conditions of the most recent executed ISAs between CONTRACTOR and LEA for so long as CONTRACTOR is servicing authorized LEA pupils, until such time as a new Master Contract is executed. Any and all changes to a LEA pupil’s educational placement/program provided under this Master Contract and/or an ISA shall be made solely on the basis of a revision to the LEA pupil’s IEP/IFSP. At any time during the term of this Master Contract, a LEA pupil’s parent, CONTRACTOR, or XXX may request a review of a LEA pupil’s IEP/IFSP subject to all procedural safeguards required by law, including notice to and participation by the CONTRACTOR in the IEP Team meeting. Unless otherwise provided in this Master Contract, the CONTRACTOR shall provide all services specified in the IEP/IFSP unless the CONTRACTOR and the LEA agree otherwise in the ISA. (California Education Code sections 56366(a) (5) and 3062(e)). In the event the CONTRACTOR is unable to provide a specific service at any time during the term of the ISA, the CONTRACTOR shall notify the LEA in writing within five (5) business days of the last date a service was provided. If a parent or XXX contests the termination of an ISA by initiating a due process proceeding with the California Office of Administrative Hearings (hereinafter referred to as “OAH”), CONTRACTOR shall abide by the “stay- put” requirement of state and federal law unless the parent agrees otherwise or an interim alternative educational placement is deemed lawful and appropriate by LEA or OAH. Disagreements between XXX and CONTRACTOR concerning the formulation of an ISA or the Master Contract may be appealed to the local SELPA office prior to appeal to the State Superintendent of Public Instruction pursuant to the provisions of California Education Code section 56366 (C) (2).

  • Outpatient Services The following services are covered only at the Primary Care Provider’s office[selected by a [Member], or elsewhere [upon prior written Referral by a [Member]'s Primary Care Provider ]:

  • Student Services 1. Students taking college classes for dual credit may utilize the same services that are available to other MCC students. MCC is responsible for ensuring timely and efficient access to such services as academic advising, learning materials (e.g., library resources), and other services for which the student may be eligible. [TAC 19, Part 1, Chapter 4, Subchapter D, §4.85 (g)(2)]

  • Payment Services 2.1 If the Payment Services is registered by the Application and the relevant Consents are submitted by the Customer, the Bank shall provide to the Customer the services (the “Payment Services”) of money transfer (“Money Transfer”) between the Accounts and other accounts as registered by the Customer.

  • Development Services During the term of this Agreement, the Provider agrees to provide to or on behalf of the Port the professional services and related items described in Exhibit A (collectively, the “Development Services”) in accordance with the terms and conditions of this Agreement. The Provider specifically agrees to include at least one Port representative in any economic development negotiations or discussions in which the Provider is involved concerning (i) a port-related business prospect or (ii) a business transaction which will ultimately require Port involvement, financial or otherwise.

  • EFT SERVICES If approved, you may conduct any one (1) or more of the EFT services offered by the Credit Union.

  • Information Services Traffic 5.1 For purposes of this Section 5, Voice Information Services and Voice Information Services Traffic refer to switched voice traffic, delivered to information service providers who offer recorded voice announcement information or open vocal discussion programs to the general public. Voice Information Services Traffic does not include any form of Internet Traffic. Voice Information Services Traffic also does not include 555 traffic or similar traffic with AIN service interfaces, which traffic shall be subject to separate arrangements between the Parties. Voice Information services Traffic is not subject to Reciprocal Compensation as Local Traffic under the Interconnection Attachment.

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