Provider-Client Services AgreementProvider-Client Services Agreement • January 2nd, 2018
This document (the Agreement) contains important information about our professional services and business policies, including potential risks and benefits of therapy, appointment policies, fee schedule and payment policies, how/when to contact us, confidentiality and its limits, and policy regarding psychotherapy with a minor. 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 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, an abbreviated version of which is included within this Agreement, explains HIPAA and its application to your personal health information in detail. An expanded version of the Notice is a
PROVIDER-CLIENT SERVICES AGREEMENTProvider-Client Services Agreement • November 27th, 2008
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 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 we provide you with a Notice of Privacy Practices (Georgia Notice Form) 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. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions y
PROVIDER-CLIENT SERVICES AGREEMENTProvider-Client Services Agreement • February 15th, 2021
Welcome to Anderson, Arnold & Partners, L.L.P. We are pleased that you chose our practice for services for yourself or your child. As we welcome you to our office, we would like to share with you some information about our professional services and business policies. Although this document is long and sometimes complex, it is very important to review this information carefully so you may be fully informed about the nature of mental health services and business practices provided at our office. We are happy to discuss any questions you have about this information as we get started and as treatment progresses. We will ask for your signature to verify that you have been given the opportunity to review the information that follows and have given consent.
