Western Carolina Medical Society Foundation Healthy Healer ProgramInformed Consent • May 2nd, 2017
The purpose of this document is to inform you of the terms of participation in Western Carolina Medical Society’s Healthy Healer Program. Please read it carefully and ask your therapist/coach if you have any questions. Return this form to your therapist/coach once completed. This document will be kept confidential and sent directly to a 3rd party law firm selected by WCMS for safekeeping. This document will not be shared with WCMS or any other party without your permission, unless required for legal purposes. This agreement holds only for self-pay patients. If you use insurance for any services you are not participating in the Healthy Healer Program and will not qualify for discounted services.
General Information & Services AgreementInformed Consent • August 1st, 2017
Welcome to my practice. This document contains information about my services and policies, and summary information about the Health Portability and Accountability Act (HIPPA). This federal law protects client rights regarding use and disclosure of Protected Health Information (PHI). HIPPA requires that I explain my privacy practices and limits, and that I obtain your signature acknowledging that I have provided you with this explanation and have your consent to use your PHI as specified.
ContractInformed Consent • August 15th, 2019
Informed Consent: The agreement given to any medical or mental health treatment (e.g., medication, procedure, or service) after the medical consenter has had the opportunity to receive sufficient information about its risks and benefits.
INFORMED CONSENT CONTRACTInformed Consent • August 20th, 2011
Confidentiality: Please understand that all records, written information, or any electronic data are marked CONFIDENTIAL and are kept under lock and key. No one inside or outside the office will have access to your case except my office assistant and me. This applies as well to the other therapists in the office. Each one of us keeps separated locked file cabinets. Computer files and insurance records are also confidential and kept on our individual password protected computers. All sessions, including telephone or email contacts are confidential to persons outside of the therapy with some exceptions. I am required by law to report:
Psychiatric Wellness Center 15 Constitution Drive, Suite 1A Bedford, NH 03110Informed Consent • November 21st, 2020
Welcome to the Psychiatric Wellness Center. This document (the Agreement) contains important information about our 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 your provider gives you a Notice of Privacy Practices (the Notice) which you will receive with this agreement, for the 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 your provider obtains your signature acknowledging that your provider has provided you with this information at the end of the first session. Although these documents are lo
Office Policies General Information Agreement Informed ConsentInformed Consent • November 17th, 2021
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.
Informed ConsentInformed Consent • October 29th, 2021
Office policies and general information agreement for psychotherapy services: This form provides you (client) with information that is additional to that detailed in the notice of privacy practices.
Tele-TherapyInformed Consent • April 24th, 2020
This informed consent adds to and does not replace the Patient Agreement you have already agreed to and signed. All those agreements also apply to tele-therapy health, including fees, billing policies, No Show/Late Cancellation policies, HIPAA requirements, and limits of confidentiality.
Appendix AInformed Consent • January 6th, 2020
You will be asked to complete a short demographic questionnaire and then engage in a semi-structured interview that will consist of twenty open ended questions. This involves answering a series of questions. Questions will include details about your previous training in Psychology, American Sign Language, and how you engage in therapeutic processes such as alliance, ruptures, and transference or counter-transference situations. You will have the opportunity to share your own personal views and feelings about working with the Deaf population and any unique differences from the working with the hearing population.
Junior Informed Consent (Age 18 years and under)Informed Consent • November 24th, 2017
CORPUS CHRISTI PODIATRY INFORMED CONSENTInformed Consent • October 24th, 2013
All information shared in this treatment is confidential except in circumstances governed by law. If you would like Corpus Christi Podiatry to confer with another healthcare professional, you will need to sign an "Authorization of Release" form. You may void this release of information at any time by signing a "Restriction Request" form.
Informed Consent for Non or Limited English Speaking Participants, and Short FormsInformed Consent • September 4th, 2014
A person’s voluntary agreement, based upon adequate knowledge and understanding of relevant information, to participate in research or to undergo a diagnostic, therapeutic, or preventive procedure. In giving informed consent, subjects may not waive or appear to waive any of the legal rights, or release or appear to release the investigator, the sponsor, the institution or agents thereof from liability for negligence. (CFR 116:21, CRF 50.20, and 50.25)
