DISCLOSURE STATEMENT *** CLIENT-CLINICIAN AGREEMENTClinician Agreement • July 2nd, 2016
This document reflects the policies of the Clinician, Michael H Gillooly, LCSW-C regarding fees, privacy of records, confidentiality of information, and other administrative issues related to the provision of professional services to the Client.
Asynchronous interpretation of manual and automated audiometry: agreement and reliabilityClinician Agreement • November 26th, 2022
Revised 2/19/19Clinician Agreement • March 12th, 2019
This document contains important information about therapy services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), the 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 we 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 has also been provided to you, explains HIPAA and its application to your personal health information in greater detail, and my practice in general accordance with HIPAA policies. The law requires that we obtain your signature acknowledging that we have provided you with this information at the end of this session.
Assumption of Risk, Waiver of Liability, and Indemnification Agreement Practice ClinicianClinician Agreement • August 2nd, 2011
I, , freely choose to participate in Wayne State University’s (“WSU”) Club Sports program as a practice clinician for the Club Team.
Monique D. Walker, PhD, MFT 1320 19th Street, NW Suite 200 * Washington, DC 20036Clinician Agreement • April 12th, 2023
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law.
Clinician Agreement on Physical FindingsClinician Agreement • July 24th, 2008
PCMH Patient-Clinician Agreement-Clinician Agreement • December 13th, 2018
A Patient-Centered Medical Home is a trusting partnership between a Clinician-led healthcare team and an informed patient. It includes an agreement between the Clinician and the patient that acknowledges the role of each in the total healthcare program.
