Common Contracts
3 similar Patient Services Agreement contracts
Pamala Roskelley MA. CMHC Certified Mental Health CounselorPatient Services Agreement • August 1st, 2020
This Agreement 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 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. The Notice of Policies and Practices to Protect the Privacy of Your Health Information (NOTICE), which accompanies this agreement and is available in the waiting room, 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.
Pamala Roskelley MA. CMHC Certified Mental Health CounselorPatient Services Agreement • April 17th, 2018
This Agreement 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 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. The Notice of Policies and Practices to Protect the Privacy of Your Health Information (NOTICE), which accompanies this agreement and is available in the waiting room, 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.
Pamala Roskelley MA., LPC Licensed Professional CounselorPatient Services Agreement • January 22nd, 2018
This Agreement 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 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. The Notice of Policies and Practices to Protect the Privacy of Your Health Information (NOTICE), which accompanies this agreement and is available in the waiting room, 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.
