International WealthClient Information & Agreement • May 25th, 2017
Thank you for making the decision to use our services. To establish your account, we need to understand your requirements and also obtain from you some additional documentation. The purpose of this form is to provide us with this information and to detail the additional documentation required. Before completing this form, please take a few moments to read the notes below.
Client Information AgreementClient Information Agreement • January 9th, 2019
I, Nicole K. Albertson, Psy.D., LLC, am dedicated to providing psychological services to children, adolescents, adults, couples and families regardless of age, race, sex, or religious affiliations. The practice of psychology is regulated by the Maryland State Department of Health and Mental Hygiene. I am committed to the client's right to information regarding office policy, non-discrimination, confidentiality, consent, and competent service.
Information for ClientsClient Information Agreement • April 13th, 2017
Welcome to my practice. I appreciate your giving me the opportunity to be of help to you and your family. I look forward to us working together. 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 new federal law that provides new privacy protections and new patients 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 require that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for testament, payment, and health care operations. The Notice, which is also included in this packet, 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
Client Information Form 客戶資料表格Client Information Agreement • April 22nd, 2019
International WealthClient Information & Agreement • April 21st, 2016
Thank you for making the decision to use our services. To establish your account, we need to understand your requirements and also obtain from you some additional documentation. The purpose of this form is to provide us with this information and to detail the additional documentation required. Before completing this form, please take a few moments to read the notes below.
