Right to Request Restrictions. You have the right to request a restriction or limitation on the health information I use or disclose about you. For example, you could ask that I not share information with an insurance company, in which case you would be responsible to pay in full for the services provided. While you are in treatment, a written request should be made. To request a restriction after therapy is completed, you must make your written request. I am not required to agree to your request, but I will consider the request very seriously. If I agree, I will abide by our agreement unless the information is needed in an emergency or by law.
Appears in 2 contracts
Samples: Agreement for Psychology Services, Agreement for Psychology Services
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information I use or disclose about you. For example, you could ask that I not share information with an insurance company, in which case you would be responsible to pay in full for the services provided. While you are in treatment, a written request should be mademade with your therapist. To request a restriction after therapy is completed, you must make your written requestrequest to the Executive Director of Xxx Xxxxx Therapeutic Counseling, LLC. I am not required to agree to your request, but I will consider the request very seriously. If I agree, I will abide by our my agreement unless the information is needed in an emergency or by law.
Appears in 1 contract
Samples: Financial Agreement
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information I we use or disclose about you. For example, you could ask that I we not share information with an insurance company, in which case you would be responsible to pay in full for the services provided. While you are in treatment, a written request should be mademade with your therapist. To request a restriction after therapy is completed, you must make your written requestrequest to the Privacy Officer of the Institute. I am We are not required to agree to your request, but I we will consider the request very seriously. If I we agree, I we will abide by our agreement unless the information is needed in an emergency or by law.
Appears in 1 contract
Samples: Service Agreement