Treatment Authorization. I request BHSI to plan and provide treatment to me (or my minor child) with my participation. I understand that I may withdraw this consent and terminate treatment at any time, for any reason. I understand that the treatment relationship is considered terminated if I have not been seen at BHSI for more than one year. I agree to have BHSI call, text, or email me to confirm appointments and/or to address billing issues. I permit XXXX to leave a phone message about my appointment.
Treatment Authorization. The owner agrees that Carolinas Veterinary Medical Hospital, in its discretion, give first aid, medication, or other attention we deem it necessary for the health, and safety of your pet. Carolinas Veterinary Medical Hospital is authorized by the owner to provide veterinary care, including emergency care, at the owner's expense. If we believe that your pet needs care, time permitting, we will attempt to contact you before providing that care, but this document serves as our authorization to provide veterinary care for your pet in the event we are unable to reach the owner. The owner is responsible for the expenses of veterinary care, whether you have been reached in advance. Your signature on this authorization permits Carolinas Veterinary Medical Hospital to make reasonable care decisions regarding your pet; and the owner agrees to pay for all costs incurred for such treatment. In the unlikely event that a pet passes away while a guest of Carolinas Veterinary Medical Hospital we will contact you and discuss your options of aftercare.
Treatment Authorization. I request Xxx Xxx, MS, LP to plan and provide treatment to me (or my minor child) with my participation. I understand that I may withdraw this consent and terminate treatment at any time, for any reason.
Treatment Authorization. Authorization for residential services will be approved by the Gateway Team. Appointments for continuing treatment in outpatient settings will be arranged prior to discharge from this treatment level.
Treatment Authorization. After providing written informed consent, potential study participants will undergo Screening assessments. The site will complete a Treatment Authorization Form (TAF) for patients determined to be eligible for study participation. The TAF includes the patient identification number, demographic information (gender, date of birth) and indication that the patient meets all inclusion and exclusion criteria. The completed TAF will be faxed to ViroMed or its designee. ViroMed or its designee will confirm whether the patient can be treated, update the TAF with specific treatment instructions, and return it to the investigational site by fax. Upon receipt, the Investigator will schedule the patient to undergo the study treatment. Note: adherence to this process is mandatory to track enrollment and to assure proper randomization.
Treatment Authorization. Authorization for Withdrawal Management Residential Services will be approved by the Gateway Team. Appointments for continuing treatment in residential settings will be arranged prior to discharge, with a plan for continued treatment at outpatient settings after the residential episode is completed.
Treatment Authorization. Contractor shall coordinate all services, excluding emergency psychiatric services, with County’s Clinical Division Directors. Contractor shall submit clinical documentation within seventy-two (72) hours of the date of service. Contractor shall use County’s forms for assessments, treatment planning, documenting progress, weekly summaries and discharges. Contractor shall request initial Mental Health Plan (MHP) payment authorization from the County for counseling, psychotherapy or other similar therapeutic interventions that meet the definition of mental health services and specialty mental health services as defined in Title 9, CCR, Section 1810.227 and Title 9, CCR, Section 1810.247, excluding services to treat emergency and urgent conditions as defined in Title 9, CCR, Sections 1810.216 and 1810.253 that will be provided on the same day that Day Treatment Intensive or Day Rehabilitation is being provided to the beneficiary. Contractor shall ensure that services provided outside of Day Treatment, on the same day of Day Treatment, document the actual time of the day the service was provided; and shall request County payment authorization for continuation of these services on the same cycle required for continuation of the concurrent day treatment intensive or day rehabilitation for the beneficiary.
Treatment Authorization. I request Stone Creek Psychiatry to plan and provide treatment to me (or my minor child) with my participation. I understand that I may withdraw this consent and terminate treatment at any time, for any reason. • I agree to have Stone Creek Psychiatry call me to confirm appointments. • I authorize Stone Creek Psychiatry to leave a phone message regarding my appointments.
Treatment Authorization. Resident authorizes the Facility to provide care and treatment consistent with the terms of this Agreement. Resident also authorizes the Facility to obtain all necessary clinical and/or financial information from the hospital or nursing facility from which Resident may be transferring.
