OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • July 2nd, 2022
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • March 21st, 2022
This document contains important information about the professional services and business policies of Horizon Psychological Services (HPS). It is important that you read it carefully and jot down any questions you might have so that they can be discussed with your treating professional. When you sign this document, it will represent an agreement between you and HPS.
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • December 29th, 2021
Welcome to Premier Psychological Counseling & Consulting & Premier TMS (PremierPCC/TMS). This document contains important information about our clinic’s professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our first meeting. When you sign this document, it will represent an agreement between us.
OUTPATIENT SERVICES AGREEMENT & OFFICE POLICYOutpatient Services Agreement • January 12th, 2021
Outpatient Services Agreement for Collateral ParticipantsOutpatient Services Agreement • May 6th, 2009
Dr.Outpatient Services Agreement • January 14th, 2019
Outpatient Services AgreementOutpatient Services Agreement • October 7th, 2019
Welcome to 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 new 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 purposes of treatment, payment, and health care operations. HIPAA requires that I provide you with a New York Notice Form that 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 at the end of our first session. Although these documents are long and complex, it is very important that you read them all before our next session. Please note any questions that you might have so that we can discuss them further. After reading this outpatient services a
Mailing: 5610 Kitsap Way Suite 350; Bremerton, WA 98312Outpatient Services Agreement • June 16th, 2017
Welcome to my practice. This document contains important information about my professional services and business practices. It also contains summary information about Health Insurance Portability and Accountability Act (HIPAA), a 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 purposes of treatment, payment, and health care operations. HIPAA requires that I provide you with a Washington State Notice of Privacy Practices Form that 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 at the end of our first session. Although these documents are long and complex, it is very important that you read them all before our next session. Please note any questions that you might have so that we can discuss them further. After reading this
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • November 10th, 2016
Welcome to Spectrum Transformation Group. This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so that you and your provider can discuss them at your next meeting. When you sign this document, it will represent an agreement between you and your provider.
Dr. Lisa Kamean-SilvaOutpatient Services Agreement • January 20th, 2022
Outpatient Services Agreement Welcome to 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 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 for use and disclosure of PHI and that I obtain your signature acknowledging that I have provided you with this information. Please read this document carefully and let me know if you have any questions.
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • May 21st, 2023
This OUTPATIENT SERVICES AGREEMENT (“Agreement”) is made by and between Tiffany Mehling, LCSW d/b/a Persist Psych, a sole proprietorship (the “Practice or Persist Psych”), Practice’s other clinical practitioners (the “Practitioner(s)”), and you (the “Patient”) of the Practice (individually, a “Party”, and collectively, the “Parties”), effective upon the date this Agreement is signed by the Patient.
GOOD LIFE CENTER FOR MENTAL HEALTH, LLC OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • November 7th, 2020
Thank you for accepting the invitation to assist in [Insert Patient’ name] psychotherapeutic treatment. Your participation is important and is sometimes essential to the success of the treatment. This document is to inform you about the risks, rights and responsibilities of your participation as a collateral participant.
OUTPATIENT SERVICES AGREEMENT/INFORMED CONSENTOutpatient Services Agreement • June 22nd, 2023
This document contains important information about my professional services and business policies. I look forward to discussing any questions with you so that I can be clear on the policies and expectations.
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • June 9th, 2015
Welcome to the Counseling and Diagnostic Center of Woodfield, Ltd. This document contains important information about the professional services and business policies of this clinic. Please read it carefully and note any questions you might have so that we can discuss them at our meeting. By signing below you agree to the policies described herein. Upon the completion of our first session, I will request that you sign this document, please review it accordingly prior to the session.
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • June 21st, 2022
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • May 18th, 2021
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • November 27th, 2024
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • August 9th, 2020
Behavioral health services are provided by licensed psychologists or licensed masters-level therapists at Savannah Behavioral Pediatrics, LLC.
Outpatient Services AgreementOutpatient Services Agreement • July 24th, 2014
Welcome to 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 new 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 purposes of treatment, payment, and health care operations. HIPAA requires that I provide you with a Indiana Notice Form that 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 at the end of our first session. Although these documents are long and complex, it is very important that you read them all before our next session. Please note any questions that you might have so that we can discuss them further. After reading this outpatient services ag
Outpatient Services Agreement for CollateralsOutpatient Services Agreement • December 8th, 2021
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • February 23rd, 2020
Your participation in your loved one’s treatment is important, and is sometimes essential to the success of the treatment. This document is to inform you about the risks, rights and responsibilities of your participation as a collateral participant.
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • February 25th, 2016
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • April 28th, 2016
Welcome to our practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions that you might have so that we can discuss them at our next meeting. Once you sign this, it will constitute a binding agreement between us.
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • August 19th, 2020
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting.
Shelley Mackaman, Ph. D. Redmond Medical CenterOutpatient Services Agreement • April 26th, 2024
Outpatient Services AgreementOutpatient Services Agreement • July 20th, 2021
Welcome to 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 with regard to the use and disclosure of your Protected Health Information (PHI) used for the purposes of treatment, payment, and health care operations. HIPAA requires that I provide you with a New York Notice Form that 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 at the end of our first session. Although these documents are long and complex, it is very important that you read them all before our next session. Please note any questions that you might have so that we can discuss them further. After reading this outpatient services agreement, yo
OUTPATIENT SERVICES AGREEMENT/INFORMED CONSENTOutpatient Services Agreement • August 9th, 2020
This document contains important information about our professional services and business policies. We look forward to discussing any questions with you so that we can be clear on the policies and expectations.
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • January 29th, 2022
Outpatient Services Agreement & Informed Consent for Psychological Assessment and TreatmentOutpatient Services Agreement • April 30th, 2013
This agreement pertains to services provided by Pediatric Associates of Iowa City and Coralville, L.L.P. CONFIDENTIALITY
Kelly Mulligan, MAOutpatient Services Agreement • November 7th, 2020
Welcome to my practice. I am pleased to have the opportunity to work with you and/or your child. This document contains important information about my professional services and business policies. Please read this handout carefully and bring any questions you may have to our next meeting so that we can discuss them.
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • April 17th, 2020
Welcome to my practice. This document contains important information about my professional services and business policies. It is important that you read it carefully and jot down any questions you might have so that we can discuss them at our first meeting. When you sign this document, it will represent an agreement between us.
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • June 12th, 2020
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • May 7th, 2021
OUTPATIENT SERVICES AGREEMENT/INFORMED CONSENTOutpatient Services Agreement • February 1st, 2017
This document contains important information about our professional services and business policies. We look forward to discussing any questions with you so that we can be clear on the policies and expectations.
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • October 17th, 2016
Welcome to Amanda Kracen, Ph.D., LLC. This Outpatient Services Agreement (the “Agreement”) contains important information about my professional services and business policies. Please read it carefully and write down any questions you might have so that we can discuss them. When you sign this Agreement, it will represent a legal contract between us.
