ContractClient Information and Services Agreement • November 8th, 2024
Confidentiality and Records: As a Board Certified Behavior Analyst at the Monocacy Start Center, I offer services without regard to age, race, gender, or religious affiliation. While I may discuss you or your child’s care with other treating providers at Monocacy Start Center in order to provide you with the most comprehensive care possible, I will not discuss treatment or release information outside of Monocacy Start Center without your written permission. I keep secure records of treatment as required by the State of Maryland. Note: state law limits confidentiality and we are mandated to report any suspected child/elder abuse or harmful intentions. We also are required to make reasonable efforts to keep our clients safe if they become suicidal.
Holly R. Counts, Psy.D.Client Information and Services Agreement • July 24th, 2011
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 new 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. 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. Although these documents are long and sometimes complex, it is very important that y
CLIENT INFORMATION AND SERVICES AGREEMENTClient Information and Services Agreement • November 10th, 2021 • Idaho
Thank you for your interest in the programs (“Programs”) offered by Run GG, LLC, an Idaho limited liability company dba Boise Betties (as “Boise Betties”)! Please read and complete all blanks on this form.
