INVERLEITH HOCKEY CLUBAdult Registration Form • September 5th, 2019
Name Which section will you be part of? Men Ladies Date of Birth Address Postcode Home Telephone Mobile Telephone Email Address
Marian Camden, Psy.D., LLC Licensed PsychologistAdult Registration Form • February 26th, 2015
Welcome to my practice. This document (the 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 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 (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, 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. You will also be offered a copy to take with you. Although these documents are long and sometime
