Common Contracts
2 similar Patient Services Agreement contracts
Michele R. Russell, Ph.D. Brookwood Center for Psychotherapy, LLCPatient Services Agreement • November 17th, 2023
This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portabili- ty and Accountability Act (HIPAA), a new federal law that 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 I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agree- ment, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although these documents are long and sometimes com- plex, it is very important that you read them caref
Michele R. Russell, Ph.D. Brookwood Center for Psychotherapy, LLCPatient Services Agreement • January 12th, 2020
This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portabil - ity and Accountability Act (HIPAA), a new federal law that 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 I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agree - ment, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although these documents are long and sometimes com- plex, it is very important that you read them car
