Common Contracts
1 similar Disclosure Statement and Services Agreement contracts
PSYCHOLOGIST-CLIENT DISCLOSURE STATEMENT AND SERVICES AGREEMENTDisclosure Statement and Services Agreement • January 7th, 2014
Welcome to my practice. This document (the Agreement) contains information about my professional services and business policies. It also contains information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides privacy protections and client rights regarding 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 Agreement, 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. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you ha
