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.
Appears in 3 contracts
Samples: Treatment Agreement, Treatment Agreement, Treatment Agreement
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.
Appears in 1 contract
Samples: Treatment Agreement
