OUTPATIENT SERVICES CONTRACT (Updated 4/12/2021)Outpatient Services Contract • March 3rd, 2022
Welcome to the Florida MH, LLC practice. This document contains important information about Florida MH, LLC’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 next meeting. When you sign this document, it will represent an agreement between you and Florida MH, LLC. Florida MH, LLC employs Dr. Si “Arthur” Chen Psy.D (“Dr. Chen”) as a Florida Licensed Psychologist - PY 10667 and a Maryland Licensed Psychologist #06586.
IDEAL LIVING PSYCHOLOGY CENTER, INC.Outpatient Services Contract • November 25th, 2020
Welcome to IDEAL LIVING PSYCHOLGY CENTER, INC. (ILPC). This document contains important information about ILPC’s professional services and business policies. Please read it carefully and jot down any questions you might have so that your clinician can discuss them at your next meeting. When you sign this document, it will represent an agreement between you and your ILPC clinician(s).
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • June 23rd, 2012
Welcome to my clinical psychology practice. This document contains important information about my professional services and business policies. This agreement also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law designed to protect your privacy and your rights regarding the use and disclosure of your Protected Health Information (PHI) for treatment, insurance reimbursement, and data analyses. Please read it carefully and jot down any questions you might have so that we can discuss them. The law requires that I obtain your signature acknowledging that you have read the information in this document, and agree to it. When you sign this document, it will represent an agreement between us. However, you may revoke this agreement at any time. That revocation will be binding except for information already discussed; obligations imposed on me by your insurance company; or any financial obligations you may have.
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • September 18th, 2009
Welcome to my practice. This document 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 at our next meeting. When you sign this document, it will represent an agreement between us.
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • January 9th, 2022
Welcome to the practice of Dr. Romy Nesin. This document contains important information about my professional services and business policies, as well as your rights and responsibilities. Please read it carefully and inform me if you have any questions. This document will constitute an agreement between us once you consent and sign on the last page.
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • February 22nd, 2017
Welcome to my practice. This document contains important information about my professional services and business policies. When you sign this document, it will represent an agreement between us. Douglas Marlow, Ph.D. is a clinical psychologist licensed by the Oregon Board of Psychologist Examiners and is a member of the American Psychological Association and the Oregon Psychological Association. Dr. Marlow provides a range of psychological services including counseling, consulting, and evaluations to individuals, groups, and families in a practice that covers all ages.
Montesinos Counseling ServicesOutpatient Services Contract • April 15th, 2023
OUTPATIENT SERVICES CONTRACT: Welcome to my practice. It is my desire to assist you in making informed decisions about your treatment; therefore, 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 during our initial meeting. Once you sign this document, it will represent an agreement between us and signify that you understand and agree to the policies and procedures of my practice. Additionally, by signing this document you are consenting to receiving treatment through my practice.
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • September 23rd, 2019
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. When you sign this document, it will represent an agreement between us.
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • May 21st, 2022
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. When you sign this document, it will represent an agreement between us.
Outpatient Services ContractOutpatient Services Contract • November 13th, 2018
Welcome to LaTonya McCurry Counseling Services, LLC. Thank you for allowing this practice to join you on your journey to recovery. This document contains important information about my professional services and business
Outpatient Services ContractOutpatient Services Contract • October 10th, 2017
Welcome to my practice. This document contains important information about my professional services, business policies, your rights as well as our mutual responsibilities and obligations. It also contains information about the Health Insurance Portability and Accountability Act (HIPPA), a federal law that provides privacy protection and patient rights about the use and disclosure of your Protected Health Information PHI). Although these documents are long and sometimes complex, they are very important that you understand them. Please read it carefully and discuss any questions you have with me. When you sign this, it will represent an agreement between us.
TREATMENT CONSENT CONTRACTOutpatient Services Contract • November 10th, 2020
Welcome to South County Psychological, Inc. This document contains important information about the professional services and business policies of Dr. Susan Novak and South County Psychological, Inc. Please read it carefully. Please feel free to ask about anything that raises questions for you. When you sign this document, it will represent an agreement between yourself and Dr. Novak.
FULCRUM PSYCHOLOGY LLCOutpatient Services Contract • February 27th, 2020
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. When you sign this document, it will represent an agreement between us.
IDEAL LIVING PSYCHOLOGY CENTER, INC.Outpatient Services Contract • August 3rd, 2023
Welcome to IDEAL LIVING PSYCHOLOGY CENTER, INC. (ILPC). This document contains important information about ILPC’s professional services and business policies. Please read it carefully and jot down any questions you might have so that your therapist can discuss them at your next meeting. When you sign this document, it will represent a legal agreement between you, ILPC and your therapist(s).
OUTPATIENT SERVICES CONTRACT (MINORS)Outpatient Services Contract • September 17th, 2018
Christy Lincoln, LCPCOutpatient Services Contract • November 18th, 2021
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. When you sign this document, it will represent an agreement between us.
Danya Weiss, Psy.D., Licensed PsychologistOutpatient Services Contract • November 18th, 2020
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. Disclosure is required by law in situations in which:
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • August 13th, 2018
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. When you sign this document, it will represent an agreement between us and consent to treatment. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action which relied on the Agreement; if there are obligations imposed on me by your health insurer or in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations. In addition, if I make any changes to my business policies I will provide you with written notification of these changes prior to their implementation. I will ask you to sign a form to acknowledge receipt of such a notification at that time.
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • August 12th, 2015
Welcome to our practice. This document 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 new privacy protections and new 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. Please read this contract carefully and note any questions you might have so that you can discuss them with your therapist. By signing this document, it will represent an agreement between you and Parker Collins. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless we have taken action in reliance on it; eg. if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • October 17th, 2021
Welcome to my practice. This document contains important information about my professional services and business policies. When you sign this document, it will represent an agreement between us. Jessica Vincenzo is a licensed clinical social worker licensed by the Oregon State Board of Licensed Social Workers as well as the Board of Oncology Social Work and is a member of the National Association of Social Workers and Association of Oncology Social Workers and has completed the Level 3 Practicum Training in Gottman Method Couples Therapy. Jessica Vincenzo, LCSW provides a range of psychological services including counseling, consulting, and evaluations to individuals and couples in a practice that covers adults.
JEANNE M. LICHMAN, Ph.D.Outpatient Services Contract • March 21st, 2012
Outpatient Services ContractOutpatient Services Contract • April 19th, 2019
Welcome to my practice. This document contains important information about my professional services, business policies, your rights as well as our mutual responsibilities and obligations. It also contains information about the Health Insurance Portability and Accountability Act (HIPPA), a federal law that provides privacy protection and patient rights about the use and disclosure of your Protected Health Information PHI). Although these documents are long and sometimes complex, they are very important that you understand them. Please read it carefully and discuss any questions you have with me.
Phone: (503) 227-3090 Fax: (971) 339-5269 OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • May 14th, 2021
This document (the Agreement) contains important information about the professional services and business policies of Dr. Marc Parker and Older Growth Psychology, LLC. 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) for the purpose of treatment, payment, and health care operations.
Outpatient Services ContractOutpatient Services Contract • June 6th, 2018
Please ask before signing below if you have any questions about psychotherapy or our office policies. Your signature indicates that you have read our Outpatient Services Contract and agree to enter therapy under these conditions. Your signature below indicates that you are making an informed choice to consent to therapy and understand and accept the terms of this agreement.
OUTPATIENT SERVICES CONTRACTOutpatient Services Contract • May 2nd, 2014
Welcome to my practice. This document contains important information about my professional practice and business policies. Please read them carefully and write down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.
Outpatient Services ContractOutpatient Services Contract • October 16th, 2017
contains important information about my professional services, business policies, your rights as well as our mutual responsibilities and obligations. It also contains information about the Health Insurance Portability and Accountability Act (HIPPA), a federal law that provides privacy protection and patient rights about the use of disclosure of your protected Health Information (PHI). While this is a long and complex document, it is important that you understand HIPPA PHI. Please read this contract and let me know if you have any questions. This contract will become a part of your file as it is an agreement between the two of us.
