PATIENT-PSYCHOTHERAPIST SERVICE AGREEMENTPatient-Psychotherapist Service Agreement • March 29th, 2010
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 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 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 included with 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 at the end of this session. Although these documents are long and sometimes complex, it is very important that
Jeremy Frank, PhD CADCPatient / Psychotherapist Service Agreement • September 8th, 2021
This document contains important information about my professional services and business policies. Please read this agreement carefully before our next session, and sign your consent on the last page. Please bring any questions or concerns you may have about this document to our next meeting. We can discuss any questions you have about the policies at that time.
