Common Contracts
1 similar Patient Services Agreement contracts
JULIE POPE DANTZLER, M.S., LMHCPatient Services Agreement • November 13th, 2020
Welcome to the practice of Julie Pope Dantzler, MS LMHC Counseling Services. This Agreement contains important information about my professional services and business policies. A summary of information is included about the Health insurance Portability and Accountability Act (HIPAA), a 1996federal law (effective April 14, 2003) that provides privacy protections and patient’s 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 (the Notice) 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 we obtain your signature acknowledging that we have provided you with this information. Although these documents are long and sometimes complex, it is very important that you
