Consent and Agreement for TreatmentConsent and Agreement for Treatment • October 7th, 2020
When we examine, diagnose, treat, or refer you we will be collecting what the law calls Protected Health Information (PHI) about you. This information may include your health records, health history, symptoms, examination and test results, diagnosis, treatment, treatment plans, and billing and health insurance information. We need to use this information to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment, or for other business (such as supervision) or required government functions (such as reporting abuse).
CONSENT AND AGREEMENT FOR TREATMENTConsent and Agreement for Treatment • March 17th, 2007
Please read the following information carefully. After you have read this Consent and Agreement, please sign your name below to accept the terms of this agreement.
CONSENT AND AGREEMENT FOR TREATMENTConsent and Agreement for Treatment • November 26th, 2012
Please read the following information carefully. After you have read this Consent and Agreement, please sign your name below to accept the terms of this agreement.
CONSENT AND AGREEMENT FOR TREATMENTConsent and Agreement for Treatment • November 28th, 2017
Please read the following information carefully. After you have read this Consent and Agreement, please sign your name below to accept the terms of this agreement.
Consent and Agreement for TreatmentConsent and Agreement for Treatment • June 15th, 2021
Please read the following information carefully. After you have read this Consent and Agreement, please sign your name below to accept the terms of this agreement.
