Consent and Service AgreementConsent and Service Agreement • August 7th, 2024
Welcome to your first session at my practice. This document 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 about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Please review carefully. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
Consent and Service AgreementConsent and Service Agreement • October 15th, 2020
Contact Information (Family, Guardian, or Legal Representative) NAME RELATIONSHIP TO RESIDENT HOME PHONE (WITH AREA CODE) WORK PHONE (INCLUDE AREA CODE) CELL PHONE (INCLUDE AREA CODE) PAGER ADDRESS EMAIL ADDRESS Private Insurance Information Complete the following if the resident has medical or dental insurance other than Medicare or Medicaid. Medical PRIMARY MEDICAL INSURANCE ADDRESS PHONE (INCLUDE AREA CODE) SUBSCRIBER’S NAME SUBSCRIBER NUMBER EMPLOYER NUMBER GROUP NUMBER Dental PRIMARY DENTAL INSURANCE ADDRESS PHONE (INCLUDE AREA CODE) SUBSCRIBER’S NAME SUBSCRIBER NUMBER EMPLOYER NUMBER GROUP NUMBER If the resident has secondary insurance, attach a separate sheet with the information required above. Service Agreement I voluntarily agree that the above named person (resident) receive services from the Residential Habilitation Center (RHC). I authorize the RHC to carry out the duties and responsibilities described in the individual habilitation plan or individual plan of care. I under
Consent and Service AgreementConsent and Service Agreement • June 5th, 2019
Contact Information (Family, Guardian, or Legal Representative) NAME RELATIONSHIP TO RESIDENT HOME PHONE (WITH AREA CODE) WORK PHONE (INCLUDE AREA CODE) CELL PHONE (INCLUDE AREA CODE) PAGER ADDRESS EMAIL ADDRESS Private Insurance Information Complete the following if the resident has medical or dental insurance other than Medicare or Medicaid. Medical PRIMARY MEDICAL INSURANCE ADDRESS PHONE (INCLUDE AREA CODE) SUBSCRIBER’S NAME SUBSCRIBER NUMBER EMPLOYER NUMBER GROUP NUMBER Dental PRIMARY DENTAL INSURANCE ADDRESS PHONE (INCLUDE AREA CODE) SUBSCRIBER’S NAME SUBSCRIBER NUMBER EMPLOYER NUMBER GROUP NUMBER If the resident has secondary insurance, attach a separate sheet with the information required above. Service Agreement I voluntarily agree that the above named person (resident) receive services from the Residential Habilitation Center (RHC). I authorize the RHC to carry out the duties and responsibilities described in this document. I understand that I may end this agreement at any tim
RESIDENT’S NAME DDA NUMBER RESIDENCE BIRTHDATEConsent and Service Agreement • October 15th, 2020
DEVELOPMENTAL DISABILIITES ADMINISTRATION (DDA) RESIDENTIAL HABILITATION CENTER (RHC) Consent and Service Agreement
CONSENT AND SERVICE AGREEMENTConsent and Service Agreement • July 12th, 2022
Qualifications: I am a Licensed Professional Counselor and an Licensed Chemical Dependency Counselor in Texas. I also have a Ph.D in Counselor Education and Supervision for the University of Texas San Antonio TX. My formal education prepares me to counsel individual adolescents and adults, groups, and families. My area of focus is in addiction and recovery services.
