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.
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.
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. 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.
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.
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.
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 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.
PATIENT SERVICES AGREEMENT. Continued
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.
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.
PATIENT SERVICES AGREEMENT. My name is Xx. Xxxx Xxxxx and you can reach me at (000) 000-0000 or by email at XxXxxxx@XxxxxXxxxxxxxxx.xxx. I am a licensed clinical psychologist. Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us. I am not immediately available by telephone. While I can often return your call promptly, I may be delayed due to various reasons such as seeing another patient. I do not check my email or voicemail evenings or weekends. When I am unavailable, you can leave a message on my confidential voicemail. I will make every effort to return your call within one business day. If you are difficult to reach, please inform me of some times when you will be available. Please leave your callback number on all messages. If you are unable to reach me and think that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychiatrist on call. I am also available by email. Please note that email is not secure so do not put any information in the email that you would not put on a postcard. If you communicate confidential or private information via unencrypted email or via phone messages, I will assume that you have made an informed decision, I will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters. You can send me text messages. I may not get them until the next business day. I do not enter phone numbers into my business phone so please sign all texts so I know who it's from.
