Common use of PATIENT SERVICES AGREEMENT Clause in Contracts

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. WELCOMEWelcome to my practice. This document (the Agreement) contains important information regarding this office’s about my professional services and business policies. It accompanies the also contains summary information you were given about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that protects provides new privacy protections and new 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 this office I provide you with a Notice of Policies and Privacy Practices to Protect the Privacy of Your Health Information (hereinafter “the Notice”) for use and disclosure of PHI for treatment, payment payment, and health care operations. The Notice, which has been provided attached to you separatelythis agreement, explains HIPAA and its applications application to your PHI personal health information in greater detail. The law requires that this office I obtain your signature acknowledging that I have provided you have been provided with this informationinformation at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before signingour next session. You We can discuss any questions you have about the procedure procedures at any time with your counselorthat time. When you sign this document, it represents will also represent an agreement between you and The Talking Place, Child and Adolescent Counseling, LLC (hereinafter “this office”)us. You may revoke this Agreement in writing at any time. That revocation will be binding on this office me unless this office has I have taken action with in reliance on it; or if there are obligations imposed on us me by your health insurer in order to process or of substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.