Common Contracts
5 similar Agreement & Informed Consent to Treatment contracts
Dr. Karin A. Mosk, Psy.D. 1125 West Street, Suite 208Agreement & Informed Consent to Treatment • August 6th, 2024
This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and 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 for use and disclosure of PHI for treatment, payment, and health care operations. The Notice 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. We can discuss any questions you have about the process. When you sign this document, it represents an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be bindi
AGREEMENT & INFORMED CONSENT TO TREATMENT-NEW YORKAgreement & Informed Consent to Treatment • May 14th, 2024
This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and 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 for use and disclosure of PHI for treatment, payment, and health care operations. The Notice 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. We can discuss any questions you have about the process. When you sign this document, it represents an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be bindi
Dr. Karin A. Mosk, Psy.D. 620 Chesapeake Ave., #2Agreement & Informed Consent to Treatment • May 14th, 2024
This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and 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 for use and disclosure of PHI for treatment, payment, and health care operations. The Notice 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. We can discuss any questions you have about the process. When you sign this document, it represents an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be bindi
Dr. Karin A. Mosk, Psy.D. 620 Chesapeake Ave., #2Agreement & Informed Consent to Treatment • April 8th, 2024
This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and 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 for use and disclosure of PHI for treatment, payment, and health care operations. The Notice 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. We can discuss any questions you have about the process. When you sign this document, it represents an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be bindi
Dr. Karin A. Mosk, Psy.D.Agreement & Informed Consent to Treatment • May 11th, 2022
This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and 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 for use and disclosure of PHI for treatment, payment, and health care operations. The Notice 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. We can discuss any questions you have about the process. When you sign this document, it represents an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be bindi
