Psychiatrist-Patient Services AgreementPsychiatrist-Patient Services Agreement • February 27th, 2023
Welcome to my practice! This document contains important information about my 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.
SOUTH TEXAS TMS GRACE M. SALINAS-GARCIA, M.D.Psychiatrist-Patient Services Agreement • August 19th, 2024
PSYCHIATRIST-PATIENT SERVICES AGREEMENTPsychiatrist-Patient Services Agreement • September 30th, 2022
Welcome to my practice. The Psychiatrist-Patient Services 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. You may revoke this Agreement in writing at any time.
Michelle L. Cantu, MD, P.A.Psychiatrist-Patient Services Agreement • July 23rd, 2015
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. Please bring up any questions you have at your first appointment.
PSYCHIATRIST-PATIENT SERVICES AGREEMENTPsychiatrist-Patient Services Agreement • September 21st, 2020
Welcome to the Family Wellness Center and South Texas TMS. The Psychiatrist-Patient Services 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. You may revoke this Agreement in writing at any time.
Michelle Rickerby MD Family Psychiatry Collaborative Suite 205, 245 Waterman Street Providence, RI 02906Psychiatrist Patient Services Agreement • January 3rd, 2024
PSYCHIATRIST-PATIENT SERVICES AGREEMENTPsychiatrist-Patient Services Agreement • January 24th, 2023
Treatment needs vary, and Dr. Wheeler will work with you to set up the most appropriate schedule. It is important to adhere to the recommended schedule of treatment. Payment is expected at the time of service. The fee for a sixty minute initial diagnostic evaluation is $500. A follow-up office visit of 25 minutes is $250.00. A follow-up office visit of 50 minutes is $500.00. If these rates should change in the future, you will be given a thirty day notice. A fee of $25.00 will be assessed to your account for any checks returned by my bank because of insufficient funds. Balances over 30 days past due will accrue a $5.00 processing fee for each month they are overdue.
Psychiatrist-Patient Services AgreementPsychiatrist-Patient Services Agreement • November 13th, 2020
Welcome to New Leaf Psychiatric Center! This document contains important information about our professional services and business policies.
Psychiatrist-Patient Services AgreementPsychiatrist-Patient Services Agreement • December 30th, 2022
Welcome to my practice! This document contains important information about my professional services and business policies. Please bring up any questions you have at your first appointment.
PSYCHIATRIST-PATIENT SERVICES AGREEMENTPsychiatrist-Patient Services Agreement • April 4th, 2011
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.
16007 Via Shavano, Ste. 101 San Antonio, TX 78249 Tel. 210-615-8900, Fax. 210-615-9400 PSYCHIATRIST-PATIENT SERVICES AGREEMENTPsychiatrist-Patient Services Agreement • February 7th, 2017
Psychiatrist-Patient Services AgreementPsychiatrist-Patient Services Agreement • June 5th, 2024
As treatment needs vary for different people, Dr. Foster will work with you to set up the most appropriate schedule. Payment is expected at the end of each session.
Psychiatrist-Patient Services AgreementPsychiatrist-Patient Services Agreement • October 2nd, 2020
Welcome to my practice. This document contains important information about my 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.
PSYCHIATRIST-PATIENT SERVICES AGREEMENTPsychiatrist-Patient Services Agreement • January 21st, 2015
Welcome to the Family Wellness Center and South Texas TMS. The Psychiatrist-Patient Services 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. You may revoke this Agreement in writing at any time.
