SHELTON EVALUATION CENTER PATIENT SERVICES AGREEMENTPatient Services Agreement • February 21st, 2024
Welcome to the Shelton Evaluation Center. This agreement contains important information about the center’s professional services and business policies, including the nature of you or your child’s evaluation, the fee arrangement, and the confidentiality of information. Although this document is long and sometimes complex, it is important that you read it carefully before the evaluation. When you sign this document, it will represent an agreement between you and the Shelton Evaluation Center (SEC). Please read it in advance and plan on meeting to discuss the agreement and any questions you may have at the time of the evaluation. The evaluation cannot proceed until you have fully read and understood this agreement in its entirety.
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.
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.
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.
PSYCHOLOGIST - PATIENT SERVICES AGREEMENTPatient Services Agreement • September 11th, 2021
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 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
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.
Jill Krilov, MDPatient Services Agreement • June 7th, 2017
Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. A separate document which will be provided for your review contains summary information about the Health Insurance Portability and Accountability Act (HIPPA), a new federal law that provides new privacy protection 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. HIPPA requires that I provide you with a Notice of Privacy Policy (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPPA 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
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.
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:
Lou Eckart, Ph.D. and Associates Licensed Clinical Psychologists 22 Mill St. Suite 109Patient Services Agreement • October 31st, 2017
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 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.
STARPASS PATIENT SERVICES AGREEMENTPatient Services Agreement • January 7th, 2020
This agreement (the “Agreement”) is made and entered into as of (the “Effective Date”) between StarMed Urgent + Family Care, P.A. (the “Company”), a corporation existing under the laws of the State of North Carolina and having its principal office at 4001 Tuckaseegee Rd., Charlotte, NC 28208 and (the “Patient”) (collectively, the “Parties”).
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.
ContractPatient Services Agreement • June 1st, 2021
Congratulations on taking the first step toward improving your mental health. We know that sometimes the most difficult part of getting help is booking that first appointment. We're honored to help you!
PSYCHOLOGIST - PATIENT SERVICES AGREEMENTPatient Services Agreement • January 28th, 2024
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 privacy protections and patient rights regarding 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 accompanies 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 by the end of our first session. Although these documents are long and sometimes complex, it is very important that you read them c
Healthier Life PLLCPatient Services Agreement • January 17th, 2021
ContractPatient Services Agreement • June 27th, 2019
Psychiatrist - Patient Services AgreementPatient Services Agreement • March 20th, 2023
Welcome to our practice! 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.
GINGER ARNOLD, PHDPatient Services Agreement • March 23rd, 2022
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. 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.
LIPP, CARLSON, WITUCKI and ASSOCIATES, LTDPatient Services Agreement • March 19th, 2020
YOUR SIGNATURE BELOW INDICATES YOU HAVE READ THE INFORMATION IN THE PATIENT SERVICES AGREEMENT (Revised 02/21/2019) AND AGREE TO ABIDE BY ITS TERMS DURING THE PROFESSIONAL RELATIONSHIP YOU HAVE WITH LIPP, CARLSON, WITUCKI and ASSOCIATES, ITS STAFF, AND ITS PROVIDERS. YOUR SIGNATURE ALSO INDICATES YOU WERE OFFERED A COPY OF THIS AGREEMENT FOR YOUR OWN RECORDS.
Ruby Y. Takushi, Ph.D.Patient Services Agreement • December 16th, 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 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 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 first session. We
PATIENT SERVICES AGREEMENTPatient Services Agreement • March 20th, 2020
Welcome to Bayer NeuroBehavioral Center. 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 privacy protections and patient rights regarding the use and disclosure of your Protected Health Information (PHI) for the purpose of treatment, payment, and health care operations. HIPAA requires we provide you with a Notice of Privacy Practices for use and disclosure of PHI. 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. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have about the procedures. When you sign this document,
PSYCHOTHERAPIST – PATIENT SERVICES AGREEMENTFOR MINOR CHILDPatient Services Agreement • November 25th, 2019
This document (Agreement) outlines the professional services and business policies of Lisa K. Schkloven, LCSW-C. My policies are in accordance with the updated Federal Health and Insurance Portability and Accountability Act (HIPPA) of 2013.
Charles M. Citrenbaum, Ph.D.Patient Services Agreement • January 2nd, 2023
Welcome to my practice. This document contains important information about my professional services and business policies. It also contains a Health Insurance Portability and Accountability Act (HIPAA) notice. HIPAA is 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 for treatment, payment and health care operations. The Notice explains HIPAA and its application to your personal health information. The law requires that I obtain your signature acknowledging that I have provided you with this information.
Diana Mansfield, LMHC, RYT - Still Waters WellnessPatient Services Agreement • November 21st, 2023
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. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although this document is long and sometimes complex, it is very important that you read it carefully before our next session. We can discuss any questions you have about the procedures at that time.
Patient Services Agreement / Consent FormPatient Services Agreement • December 24th, 2022
Welcome to the May Evaluation Center. This agreement contains important information about the center’s professional services, business policies, and the confidentiality of information. Please read it carefully before the evaluation. When you sign this document, it will represent an agreement between you and the May Evaluation Center (MEC). Read it in advance and bring any questions you may have at the time of the evaluation. The evaluation cannot proceed until you have fully read, understood, and signed this agreement.
Patient Services Agreement Synapse Association, Inc.Patient Services Agreement • August 20th, 2020 • California
Kimberly Mathewson, Psy.D.Patient Services Agreement • January 14th, 2023
In order to provide you with the best service, and to meet the legal requirements of the State of Colorado, I would like to provide you with the following information:
Patient Services Agreement Synapse Association, Inc.Patient Services Agreement • January 20th, 2020
ContractPatient Services Agreement • November 18th, 2020
PATIENT SERVICES AGREEMENTPatient Services Agreement • February 1st, 2022 • Kentucky
This Patient Services Agreement (hereinafter referred to as the “Agreement”) is made and entered into on this day of , 201_ (the “Effective Date”) by and between Olive Health, PLLC d/b/a Olive Health Direct Primary Care, a Kentucky professional limited liability company, (hereinafter referred to as the “Practice”), and (hereinafter referred to as the “Patient”).
Seattle, WA 98121Patient Services Agreement • June 17th, 2021
• I have reviewed the services provided and not provided by Equinox and I have had the opportunity to ask questions and receive answers regarding this.
PATIENT SERVICES AGREEMENTPatient Services Agreement • May 2nd, 2018
Welcome to Nolan Speech & Language Center. This document contains important information about our professional services and business policies. It also reminds you of your opportunity to obtain and read a copy of policies and procedures under the Health Insurance Portability and patient’s rights with regard to the use and disclosure of Protected Health Information (PHI) used for purpose of payment, treatment, and health care operations. HIPAA requires that you be provided with a Notice of Privacy Policies at your request.
