Carol Lieser, PhD APRN PMHNP BC Ana Castellanos, MSN APRN PMNP BCPatient Treatment Agreement • August 18th, 2021
This patient agreement and our policies and procedures have been adopted to ensure proper and appropriate treatment for all of my patients. So that we can give you the best care and experience possible, we ask that you read, sign, and kindly remember our practice policies and procedures.
Patient Treatment AgreementPatient Treatment Agreement • April 27th, 2017
The purpose of this agreement is to inform me about the use of pain medications and to ensure that I and [PHYSICIAN NAME] comply with all state and federal regulations concerning the prescribing of controlled substances. My compliance with this agreement is necessary to ensure that [PHYSICIAN NAME] can effectively prescribe opioids and other medication to decrease my pain and provide an improved quality of life.
Nu Yu AcupuncturePatient Treatment Agreement • May 31st, 2020
If I have or anyone I have been in contact with have experienced any symptoms associated with COVID-19 (Fever, Shortness of Breath, Dry Cough, Runny Nose, Sore Throat, Loss of Taste or Smell) I will notify Nu Yu Acupuncture and cancel my appointment.
Novus Spine & Pain Center Patient Treatment Agreement and Clinic GuidelinesPatient Treatment Agreement • September 15th, 2016
PATIENT TREATMENT AGREEMENTPatient Treatment Agreement • October 25th, 2020
PATIENT TREATMENT AGREEMENT AND FINANCIAL DISCLOSUREPatient Treatment Agreement • August 17th, 2020
Thank you for choosing Advanced Physicians, P.C. (the “Practice”) to assist you with your medical needs. This is our Patient Agreement and Financial Disclosure, which will specify our agreement with you regarding the treatment we provide. Please review the provisions below, and let our staff know if you have any questions.
MAT Expansion in Rural Oklahoma Example Patient Treatment AgreementPatient Treatment Agreement • June 23rd, 2017
As a recipient of outpatient treatment with buprenorphine/naloxone (for example, Suboxone) or buprenorphine (for example, Subutex), referred to generally as “buprenorphine” below, for treating my problems with opioid use, these guidelines are given to me to help me stay safe and do the things I need to do for my continued recovery.
Contract for Patients Prescribed Opiate PharmacotherapyPatient Treatment Agreement • September 11th, 2021
Patient Treatment AgreementPatient Treatment Agreement • August 19th, 2023
Our intent is to provide you with services consistent with the best practice standards in order to achieve the most successful outcome possible. This is a team approach involving you and your physician.
Patient Treatment Agreement: Medical CannabisPatient Treatment Agreement • May 2nd, 2019
I, understand that I will be receiving a medical document from prescriber which will authorize me to purchase cannabis (marihauna, marijuana) for a medical purpose.
PATIENT TREATMENT AGREEMENTPatient Treatment Agreement • October 26th, 2022
CONSENT FOR SERVICES/INFORMATION: I voluntarily consent to physical therapy services rendered by Compass Physical Therapy LLC Employees as ordered by my physician and physical therapist. I understand that I will be informed of all proposed medical procedures and treatment prior to commencement and that I have the right to refuse any proposed medical procedure or treatment. I also understand that with all medical intervention there are risks involved and that no guaranteed outcome can be made.
Patient Treatment AgreementPatient Treatment Agreement • April 14th, 2023
At Waterstone we want the best outcomes for patients and as such having a treatment agreement to help the treatment team and the patient to work together on a safe and effective plan for success is the best way to achieve the goals.
Serene Minds, LLCPatient Treatment Agreement • March 4th, 2017
Patient Treatment AgreementPatient Treatment Agreement • November 22nd, 2022
You are required to adhere to the policies of The Pain Medicine & Rehabilitation Center (PMRC) or you will be discharged from our care. Our goal is to provide safe and effective treatment for your Chronic Pain Syndrome while protecting the community from the risk of drug abuse which may result in death. Your partnership with this treatment agreement is the first step toward our goal.
Donna Bartlett, LCSW, LCAS, CMHt PROVIDER – PATIENT TREATMENT AGREEMENTPatient Treatment Agreement • April 16th, 2018
Welcome! This document contains important information about my practice and business policies. This document also contains brief information about the Health Insurance Portability and Accountability Act (HIPAA) a federal law designed to protect your privacy and your 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 the additional notice of Privacy Practices that explains HIPAA and how it affects you. The law also requires that we obtain your signature acknowledging that you have received this information
Carol Lieser PhD APRN PMHNP BC In His Image PsychiatryPatient Treatment Agreement • September 6th, 2016
This patient agreement and our policies and procedures have been adopted to ensure proper and appropriate treatment for all of my patients. So that I can give you the best care and experience possible, I ask that you read, sign and kindly remember my practice policies and procedures.
Carol Lieser, PhD APRN PMHNP BC In His Image PsychiatryPatient Treatment Agreement • February 14th, 2022
This patient agreement and our policies and procedures have been adopted to ensure proper and appropriate treatment for all of my patients. So that I can give you the best care and experience possible, I ask that you read, sign, and kindly remember my practice policies and procedures.
Patient Treatment Agreement For Use of Controlled Substances in Treating Chronic PainPatient Treatment Agreement • April 6th, 2017
The purpose of this agreement is to inform me about the use of pain medications and to ensure that I and [PHYSICIAN NAME] comply with all state and federal regulations concerning the prescribing of controlled substances. My compliance with this agreement is necessary to ensure that [PHYSICIAN NAME] can effectively prescribe opioids and other medication to decrease my pain and provide an improved quality of life.
Carol Lieser PhD APRN PMHNP BC In His Image PsychiatryPatient Treatment Agreement • July 2nd, 2022
This patient agreement and our policies and procedures have been adopted to ensure proper and appropriate treatment for all of my patients. So that I can give you the best care and experience possible, I ask that you read, sign and kindly remember my practice policies and procedures.
Carol Lieser, PhD APRN PMHNP BC In His Image PsychiatryPatient Treatment Agreement • November 1st, 2021
This patient agreement and our policies and procedures have been adopted to ensure proper and appropriate treatment for all of my patients. So that I can give you the best care and experience possible, I ask that you read, sign and kindly remember my practice policies and procedures.
Patient Treatment AgreementPatient Treatment Agreement • March 10th, 2020
• We now understand opioid drugs make only little or no difference to long term pain and if so, only at low, intermittent doses.
Patient Treatment AgreementPatient Treatment Agreement • August 20th, 2021
I agree to conduct myself in a courteous manner. I will treat Headache Center staff and providers with respect and dignity whether in the clinic or on the phone. Non-adherence will result in discharge from the practice.
PATIENT TREATMENT AGREEMENTPatient Treatment Agreement • March 19th, 2020
This is an agreement between you, the patient, and Neuro Behavioral Center LLC (NBC). It addresses certain conditions with regards to your treatment, the use of your medical records insurance benefits, and other NBC policies. In consideration of receiving NBC services, you agree to the following:
INDER BHANVER, M.D., PLLC - Patient Treatment AgreementPatient Treatment Agreement • November 18th, 2011
Carol Lieser, PhD APRN PMHNP BC In His Image PsychiatryPatient Treatment Agreement • September 22nd, 2022
This patient agreement and our policies and procedures have been adopted to ensure proper and appropriate treatment for all of my patients. So that I can give you the best care and experience possible, I ask that you read, sign and kindly remember my practice policies and procedures.
Sample Patient Treatment AgreementPatient Treatment Agreement • September 23rd, 2020
ContractPatient Treatment Agreement • August 1st, 2016
This form is provided for educational and informational purposes only. It is not intended to establish a legal or medical standard of care. Physicians should use their personal and professional judgment in interpreting this form and applying it to the particular circumstances of their individual patients and practice arrangements. The information provided in this form is provided “as is” with no guarantee as to its accuracy or completeness. ASAM will strive to update this form from time to time, but cannot ensure that the information provided herein is current at all times.
PATIENT TREATMENT AGREEMENT FOR SAFE AND EFFECTIVE USE OF OPIOIDS FOR CHRONIC NON-CANCER PAINPatient Treatment Agreement • June 18th, 2014
PATIENT TREATMENT AGREEMENTPatient Treatment Agreement • September 11th, 2021
• You agree to keep all scheduled appointments, not just with your physician, but also with recommended therapists and psychological counselors. Three or more missed appointments or same day cancellations will lead to patient dismissal.
PATIENT TREATMENT AGREEMENTPatient Treatment Agreement • January 25th, 2020
PATIENT TREATMENT AGREEMENTSPatient Treatment Agreement • July 24th, 2014
Why an agreement? The medication we are prescribing has the potential to provide much benefit, but it also can do harm to you or others. Misuse of pain medications is becoming a large problem in our community. We are doing our part to ensure that our prescriptions are taken as directed. We also want to protect you and inform you concerning the uses and abuses of this medication.
PATIENT TREATMENT AGREEMENTPatient Treatment Agreement • September 7th, 2016
• You agree to keep all scheduled appointments. Three or more missed appointments or same day cancellations will lead to patient dismissal.
Patient Treatment Agreement / Patient Accountability LetterPatient Treatment Agreement • March 25th, 2020
The purpose of this agreement is to establish accountability measures for you in connection with this office’s treatment of your chronic pain condition. We believe the accountability measures protect your access to the controlled substances you and your doctor’s ability to use controlled
PATIENT TREATMENT AGREEMENTPatient Treatment Agreement • December 4th, 2017
