Common Contracts
1 similar Outpatient Services Contract contracts
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • June 23rd, 2012
Welcome to my clinical psychology practice. This document contains important information about my professional services and business policies. This agreement also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law designed to protect your privacy and your rights regarding the use and disclosure of your Protected Health Information (PHI) for treatment, insurance reimbursement, and data analyses. Please read it carefully and jot down any questions you might have so that we can discuss them. The law requires that I obtain your signature acknowledging that you have read the information in this document, and agree to it. When you sign this document, it will represent an agreement between us. However, you may revoke this agreement at any time. That revocation will be binding except for information already discussed; obligations imposed on me by your insurance company; or any financial obligations you may have.
