Common Contracts
2 similar Services Agreement contracts
Neuropsychology & Concussion Management Associates, LLC (NCMA) Services Agreement and Consent FormServices Agreement • July 25th, 2022
This document contains information about our professional services and business policies. It also provides information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides certain privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information. HIPAA requires that we provide you with a Notice of Privacy Practices; this is available to you at www.NCMAmaine.com and in our waiting room and from our office staff. We will mail it to you on request. In order to provide services to you, we require your signature acknowledging that we have provided you with access to this information and that you have given your informed consent to the services and the practices described in this document. When you sign this document, it will represent an Agreement between us. You may cancel this Agreement in writing at any time. That cancellation will be binding except 1) to the extent that we have already taken ac
Services Agreement and Consent Form for Neuropsychological and/or Concussion Management ServicesServices Agreement • January 13th, 2021
This document contains information about our professional services and business policies. It also provides information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides certain privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information. HIPAA requires that we provide you with a Notice of Privacy Practices; this is available to you at www.NCMAmaine.com and in our waiting room and from our office staff. We will mail it to you on request. In order to provide services to you, we require your signature acknowledging that we have provided you with access to this information and that you have given your informed consent to the services and the practices described in this document. When you sign this document, it will represent an Agreement between us. You may cancel this Agreement in writing at any time. That cancellation will be binding except 1) to the extent that we have already taken ac
