Common Contracts
1 similar Consent Agreement contracts
INFORMED CONSENT AGREEMENTConsent Agreement • May 23rd, 2016
This Agreement contains important information about clinic professional services and business policies. It also contains summary information about the health Insurance Portability and Accountability Act (HIPAA), a federal law that provides 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. HIPPA requires that you be provided with a Notice of Privacy Practices for use and disclosure of PHI for treatment, payment and health care operations. This Notice, which is enclosed with this agreement, explains HIPAA and its application to your personal health information. Your therapist can discuss any questions you have about the procedures. When you sign this document, it will also represent an agreement between you and the clinic. You may revoke this Agreement in writing at any time. That revocation will be binding unless action has been takin in reliance
