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.
ContractPatient Treatment Agreement • January 31st, 2022
In order to schedule your admission appointment, please complete all included documents. The checklist below has been provided to assist you.
PATIENT TREATMENT AGREEMENTPatient Treatment Agreement • October 25th, 2020
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 AGREEMENT – MEDICAL CANNABISPatient Treatment Agreement • April 5th, 2017
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 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.
Anthem HealthKeepers Plus Hepatitis C Therapy Patient Treatment AgreementPatient Treatment Agreement • December 21st, 2017
Prescriber instructions: Please submit the completed agreement with the initial prior authorization requests. Patient instructions: By reading and signing this agreement, I acknowledge that I have been informed about the requirements of the treatment program and understand what is expected of me. I can refuse to sign this agreement, but treatment will not be started until and unless I sign this agreement.
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 • 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:
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 7th, 2016
• You agree to keep all scheduled appointments. Three or more missed appointments or same day cancellations will lead to patient dismissal.
Carol Lieser, PhD APRN PMHNP BC Ana Castellanos, MSN APRN PMNP BCPatient Treatment Agreement • May 6th, 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 • December 4th, 2017
