Common Contracts
2 similar Consent to Services Enrollment Agreement contracts
Consent to Services Enrollment AgreementConsent to Services Enrollment Agreement • August 3rd, 2020
(“Board”). I acknowledge that I have self-referred to Integrated Behavioral Health, LLC, Health Professionals’ Services Program (“Program”) and previous to this date and pursuant to my Provisional Enrollment Agreement, I have been diagnosed by a Board-approved independent third-party evaluator as having a:
Consent to Services Enrollment AgreementConsent to Services Enrollment Agreement • February 17th, 2020
(“Board”). I acknowledge that I have self-referred to Integrated Behavioral Health, LLC, Health Professionals’ Services Program (“Program”) and previous to this date and pursuant to my Provisional Enrollment Agreement, I have been diagnosed by a Board-approved independent third-party evaluator as having a:
