ContractCounselor – Client Services Agreement • April 1st, 2021
Counselor-Client Services AgreementCounselor-Client Services Agreement • November 18th, 2020
This document outlines my policies and guidelines and also contains important information about the Health Insurance Portability and Accountability Act or HIPAA. This is a federal law that provides privacy protections and client rights regarding the use and disclosure of your Protected Health Information. This information is collected and used for the purpose of treatment, payment, and health care practices.
Counselor-Client Services AgreementCounselor-Client Services Agreement • October 11th, 2016
Welcome to my practice! This document contains important information about my services and policies. Please review all the following information carefully as it will represent an agreement between us. You may revoke this agreement in writing at any time. That revocation will be binding on us unless I have taken action in reliance on it, such as: (1) if there are obligations imposed on me by your health insurer in order to process claims made under your policy, or (2) if you have not satisfied any financial obligation you have incurred within 30 days of receiving balance notification.
COUNSELOR - CLIENT SERVICES AGREEMENTCounselor - Client Services Agreement • October 21st, 2015
**Although this document is long and sometimes complex, it is very important that you read it carefully before your next appointment**
Zanda Hilger, LPC Licensed Professional CounselorCounselor - Client Services Agreement • August 1st, 2020
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 federal law that provides privacy protections and Client 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. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss a
COUNSELOR - CLIENT SERVICES AGREEMENTCounselor - Client Services Agreement • August 11th, 2010
My signature below indicates that I have received and had the opportunity to read and discuss the Counselor- Client Services Agreement. I understand and agree to its terms and I willingly grant permission for me or my child to be treated by RHEMA Counseling & Support Services, PC.
ContractCounselor-Client Services Agreement • January 2nd, 2014
MEETINGSCounselor-Client Services Agreement • December 27th, 2017
This counselor will not exceed his limitations. He will keep your rights primary, and will not enter into any kind of inappropriate relationship with the counselee. This counselor will not use any treatment procedures that he has not been professionally trained in. All information shared in the counseling environment will remain private and confidential. Often times, the success of counseling depends, at least in part, on how comfortable the counselee and the counselor are with each other. This is known as the thereputic relationship. A referral may be made upon your request or upon the counselor’s recommendation.
Counselor-Client Services Agreement and Notice of Privacy PracticesCounselor-Client Services Agreement • September 17th, 2020
Welcome to my counseling 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). HIPAA is a Federal law that provides privacy protection and 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 I provide you with a Notice of Privacy Practices (the Notice). The Notice, which is incorporated here, explains HIPAA and its application to your personal health information. The law requires me to obtain your signature acknowledging that I have provided you with this information. Although this document is long, please read it carefully. We can discuss any questions you have about its content. When you sign the Acknowledgement of Notice of Privacy Practice and Service Agreement, it will represent an agreement
ASHLEY HERRON, MS BIBLICAL COUNSELORCounselor – Client Services Agreement • February 22nd, 2022
Welcome to Destined to Win, LLC! This agreement is intended to provide clients with important information regarding my professional services and business policies. It also contains summary
COUNSELOR-CLIENT SERVICES AGREEMENTCounselor-Client Services Agreement • April 20th, 2021
Counselor-Client Services AgreementCounselor-Client Services Agreement • December 27th, 2021
This document outlines policies and guidelines and also contains important information about the Health Insurance Portability and Accountability Act or HIPAA. This is a federal law that provides privacy protections and client rights regarding the use and disclosure of your Protected Health Information. This information is collected and used for the purpose of treatment, payment, and health care practices.
COUNSELOR-CLIENT SERVICES AGREEMENTCounselor-Client Services Agreement • October 12th, 2021
This form has been developed to provide you with information about counseling procedures and practices. It contains information about the Health Insurance Portability and Accountability Act (HIPPA) Privacy rule, and some professional ethical codes relevant to therapy. You may choose to revoke this agreement at any time, which will mean you no longer consent to treatment, however, some parts may still be enforced.
COUNSELOR - CLIENT SERVICES AGREEMENTCounselor - Client Services Agreement • July 26th, 2014
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 federal law that provides privacy protections and 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 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. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have about the proc
