LICENSED CLINICAL SOCIAL WORKER-PATIENT SERVICES AGREEMENTPatient Services Agreement • May 13th, 2014
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the LCSW and patient, and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.
HRC PROVIDER-PATIENT SERVICES AGREEMENTPatient Services Agreement • October 14th, 2020
Your initial session(s) will involve an evaluation of your needs. By the end of the evaluation, your provider will be able to offer you some first impressions of what your work will include and a plan to follow, if you decide to continue with our services. You should evaluate this information along with your own opinions of whether you feel comfortable working with your provider. Treatment/consultation involves a commitment of time, money, and energy, so you should be careful about the provider you select. If you have questions about procedures, they should be discussed with your provider whenever they arise. If your doubts persist, your provider will be happy to help you set up a meeting with another professional for a second opinion.
New Patient Services AgreementPatient Services Agreement • June 4th, 2021
This form is an agreement between you, (parent of a minor or adult client) , and Behavioral Health Clinic (BHC). When we use the word “patient” below, it can mean you, your child, a relative or other person if you have written his or her name here: .
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPatient Services Agreement • January 28th, 2022
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 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 at the end of this session. Although these documents are long and sometimes complex, it is very important that y
PATIENT SERVICES AGREEMENTPatient Services Agreement • December 21st, 2023
Welcome to Ruah Woods Psychological Services (RWPS). RWPS is a branch of Ruah Woods Institute, a Catholic nonprofit ministry founded in 2008. Ruah Woods seeks to help men and women live their vocation to love, according to God’s plan, as informed by Pope St. John Paul II’s “Theology of the Body.” RWPS aids this mission by developing and providing high quality psychological services grounded in the Catholic vision of the human person to empower people to more fully embrace and live out their vocation to love according to God’s plan. The services we provide include psychotherapy, psychological evaluation, psychoeducation (e.g., speaking and writing), and consultation/training. Although our services are available to anyone regardless of religious affiliation or belief, RWPS therapists may incorporate and will follow Catholic doctrine and moral teaching in our provision of these services.
Paul Beljan, PsyD, ABPdN, ABN Vanessa Berens, PhD Casey Heinsch, MAS, LAMFT Jodie Graham, MSPatient Services Agreement • August 30th, 2021
Patient Services AgreementPatient Services Agreement • November 20th, 2020
This Patient Service Agreement governs the relationship between Alamo City Urgent Care and patients who enroll in one of our monthly membership programs.
Pamala Roskelley MA. CMHC Certified Mental Health CounselorPatient Services Agreement • August 1st, 2020
This 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 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. The Notice of Policies and Practices to Protect the Privacy of Your Health Information (NOTICE), which accompanies this agreement and is available in the waiting room, 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.
INFORMED CONSENT & THERAPIST-PATIENT SERVICES AGREEMENTPatient Services Agreement • November 29th, 2020
As you know, I work with a network of independent mental health professionals, under the name of InSight Counseling, LLC. This group is an association of independent practitioners who share certain expenses and administrative functions. While the independent practitioners share a name and office space, I want you to know that I am completely independent in providing you with clinical services and I alone am fully responsible for those services. My professional records are confidential and no member of the group can have access to them without your specific, written permission.
Michele R. Russell, Ph.D. Brookwood Center for Psychotherapy, LLCPatient Services Agreement • November 17th, 2023
This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portabili- ty 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 attached to this Agree- ment, 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 com- plex, it is very important that you read them caref
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPatient Services Agreement • August 3rd, 2020
Welcome to our practice. This document (the Agreement) contains important information about our professional services and business policies. When you sign the Agreement, it will represent an agreement between us. (Note: You will sign this Agreement on the Billing and Insurance Information page of the paperwork.) 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; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
Lisa A. Wuyek, Ph.D.Patient Services Agreement • October 6th, 2021
This document contains important information about my professional services and business policies. It also contains summary information about the Health Information 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) 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, health care operations. The Notice contains a description of HIPAA and its application to your PHI. I am required to obtain your signature acknowledging that I have provided you with this information prior to your first session.
Jessie Garcia, Ph.D. Licensed PsychologistPatient Services Agreement • November 21st, 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 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 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 at the end of this session. Although these documents are long and sometimes complex, it is very important that y
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT [NEW YORK]Patient Services Agreement • May 12th, 2015
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 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 at the end of this session. Although these documents are long and sometimes complex, it is very important that y
CornerstonePatient Services Agreement • January 27th, 2022
Welcome to our clinic. 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 we 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 we obtain your signature acknowledging that we have provided you with this information.
Pediatric Neuropsychological Services of Alaska, PCPatient Services Agreement • February 10th, 2019
Psychotherapist-Patient Services AgreementPatient Services Agreement • January 9th, 2020
This information is designed to help you understand the therapeutic process and the specifics of my counseling practice. It can feel overwhelming to begin the process of therapy, and this document is to help outline the specifics of what we do in the counseling office. It is important that you have a clear idea of how we will work together, and so after we go over this document, I will ask you to sign the agreement, stating that you have understood the information contained here. When you sign this document, it will represent an agreement between us. Please ask if you have any questions about this document or the therapy process, now or in the future.
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPatient Services Agreement • October 28th, 2020
This description of my professional services and business policies should answer most questions you may have. Please feel free to ask any unanswered questions and to discuss other concerns you may have as the need arises. This Agreement 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 describing these protections and rights. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail.
Psychologist-Patient Services AgreementPatient Services Agreement • November 6th, 2020
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 we 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 we obtain your signature acknowledging that we 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 you read them carefully before yo
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPatient Services Agreement • May 24th, 2022
This document (the Agreement) contains important information about the therapist’s 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 the therapist 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 in your intake packet, explains HIPAA and its application to your personal health information in greater detail. The law requires that the therapist obtain your signature acknowledging that the therapist has provided you with this information by the end of our first session. We can discuss any questions you have about this ag
Psychiatric Associates Of Northern VirginiaPatient Services Agreement • January 19th, 2019
Welcome to Psychiatric Associates of Northern Virginia (PANV) This document contains important information about our professional services and business policies. It also contains 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. You may revoke this Agreement in writing at any time. Please bring up any questions you have at your first appointment.
ContractPatient Services Agreement • October 26th, 2020
Welcome to Universal Counseling, LLC. 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). HIPAA requires that Universal Counseling, LLC 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 Universal Counseling, LLC obtain your signature acknowledging that you have been provided this information. Although these documents are long and sometimes complex, it is very important that you read them carefully, and we can discuss any qu
PATIENT SERVICES AGREEMENTPatient Services Agreement • January 13th, 2023
By agreeing to be treated by Kenneth Wilstead, DMD, PA (hereinafter referred to as the “Practice”), the Patient agrees that the Practice shall not give a refund of monies back to the Patient, under any circumstances, and also agrees to the following items listed below:
PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPatient Services Agreement • March 19th, 2008
Welcome to the clinical practice of Dr. Tamsen Thorpe, a Licensed Psychologist. 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.
PATIENT SERVICES AGREEMENTPatient Services Agreement • September 13th, 2021
This Patient Services Agreement governs the relationship between Range Urgent Care and patients who enroll in one of our monthly membership programs.
Avery Hoenig, Ph.D. Licensed Psychologist #33013Patient Services Agreement • February 18th, 2020
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 new 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 healthcare 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 at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session.
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPatient Services Agreement • August 29th, 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 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 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 at the end of this session. Although these documents are long and sometimes complex, it is very important that y
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT CONSENT FOR TREATMENTPatient Services Agreement • July 16th, 2015
Thank you for selecting Greenwood Counseling service to assist you. I will do all I can to help with your situation. If you have questions about services, please feel free to discuss your concerns with me. Below is information regarding policies, procedures and services.
PSYCHOLOGIST/MENTAL HEALTH PROFESSIONAL PATIENT SERVICES AGREEMENTPatient Services Agreement • June 23rd, 2013
This document is a summary of information about Psychological Service Associates, Inc.’s (PSA) professional services and business policies (a complete copy of this Agreement is available upon request). 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.
HEALTHCARE PROVIDER / PSYCHOTHERAPIST—PATIENT SERVICES AGREEMENTPatient Services Agreement • July 14th, 2008
Welcome, I am pleased you have chosen me as your healthcare provider. Please read the following document carefully as it contains important information about my professional services and practice policies.
PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPatient Services Agreement • June 19th, 2022
Welcome to Psychology and Beyond! Our core values celebrate compassion, inclusivity, and connectedness. Our mission as a psychotherapy practice is to provide caring, culturally-sensitive, and effective care that helps you to achieve your highest potential, provides you with clarity and increased self-awareness, and eventually leads to meaningful life change. This document contains important information about professional services and business policies at Psychology and Beyond, LLC. Please read it carefully and write down any questions you might have so that you can discuss them with your psychologist at your next meeting.
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPatient Services Agreement • November 17th, 2017
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 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 at the end of this session. Although these documents are long and sometimes complex, it is very important that y
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPatient Services Agreement • December 13th, 2017
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 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 for use and disclosure of PHI for treatment, payment and health care operations. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session.
ANDREW MCGARRAHAN, Ph.D. CLINICAL PSYCHOLOGY 12820 Hillcrest Road, Ste.217 Dallas, Texas 75230Patient Services Agreement • November 10th, 2020
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 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 at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next s
Nicholasville, Kentucky 40356Patient Services Agreement • April 26th, 2008
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 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 at the end of this session. Although these documents are long and sometimes complex, it is very important that y
