Dr. Eileen R. BorrisPsychologist-Client Agreement • April 16th, 2020
Welcome to my practice! This document (the “Agreement”) contains important information about my professional services and policies. It is intended to help clients understand how my practice operates with respect to the psychologist-client relationship. Please read this information and ask me any questions you may have. Your signature on this document will represent an Agreement between us. You may revoke this Agreement in writing at any time, and that revocation will be binding unless: a) I have taken action in reliance on it; b) your health insurer imposes obligations on me in order to process or substantiate claims made under your policy; or c) you fail to satisfy any financial obligations you have incurred.
Stephanie Dodge, PhDPsychologist-Client Agreement • April 21st, 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 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 for use and disclosure of PHI for treatment, payment, and health care operations. The Notice, which follows these Office Policies and is included as part of the services 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 our first session.
Psychologist – Client AgreementPsychologist-Client Agreement • January 31st, 2016
This document 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). HIPAA requires that I provide you with a Notice of Policies and Practices to protect the privacy, use, and disclosure of PHI for treatment, payment, and health care operations. The law requires that I obtain your signature acknowledging that I have provided you with this information. Both the Notice and the Signature Page are attached to this document, and explain HIPAA and its application to your personal health information in greater detail. Although these documents are long and can be complex, it is very important that you read them carefully before our next session. For both the Psychologist-Client Agreement and the HIPAA forms – please bring any questions or concerns to our next meeting so that we can discuss them.
PSYCHOLOGIST – CLIENT AGREEMENT (CLIENT COPY)Psychologist – Client Agreement • May 5th, 2016
Kinexus psychology is committed to ensuring that personal information collected is dealt with in accordance with the Information Privacy Principles contained in the Information Privacy Act 2009.
NYC COUNSELING PLLCPsychologist-Client Agreement • November 21st, 2020
This section 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. HIPAA requires that we provide you with a Notice of Privacy Practices for use and disclosure of PHI for treatment, payment, and health care operations. The Notice, which follows these Office Policies and is included as part of the services 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 has provided you with this information at the end of our first session.
Teresa B. Olson, PsyDPsychologist-Client Agreement • March 12th, 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 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 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. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions
