ContractPsychologist-Client Service Agreement • April 1st, 2022
Welcome to my practice. 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 privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
Dr. Pearl Zurich & AssociatesPsychologist-Client Service Agreement • December 16th, 2021
Welcome to my practice. This document contains important information about my professional services and business policies. It also contains a summary of the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us.
PSYCHOLOGIST-CLIENT SERVICE AGREEMENTPsychologist-Client Service Agreement • December 31st, 2020
Welcome to my practice. 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 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 at the end of this session. 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
SHIDEH LENNON, PH.D. CLINICAL PSYCHOLOGIST NYS Lic. # 013428Psychologist-Client Service Agreement • March 11th, 2016
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, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail.
PSYCHOLOGIST-CLIENT SERVICE AGREEMENTPsychologist-Client Service Agreement • October 26th, 2017
Welcome to my practice. This document contains important information about my professional services and business policies.When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
DR. GINA MADRIGRANOPsychologist-Client Service Agreement • August 2nd, 2020
PSYCHOLOGIST-CLIENT SERVICE AGREEMENTPsychologist-Client Service Agreement • July 21st, 2016
Welcome to my practice. I appreciate the opportunity to work with you. 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 privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
INFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISISPsychologist-Client Service Agreement • February 2nd, 2021
This document contains important information about our decision (yours and mine) to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let me know if you have any questions. When you sign this document, it will be an official agreement between us.
ContractPsychologist-Client Service Agreement • September 6th, 2006
Peter Tolisano, Psy.D., LLC Board Certified in Clinical PsychologyPsychologist-Client Service Agreement • November 4th, 2020
My signature indicates that (1) I have read all the information in the Psychologist-Client Service Agreement and HIPAA Notice of Privacy Practices; (2) I fully understand the stated policies; (3) I consent to treatment; (4) I agree to abide by the terms outlined in this document during our professional relationship; (4) I have been offered a copy of this Agreement and HIPAA Notice for my records; and (5) that I have been offered the opportunity to ask questions about this document at the outset of treatment and in the future.
PSYCHOLOGIST-CLIENT SERVICE AGREEMENTPsychologist-Client Service Agreement • January 27th, 2022
Welcome to my practice. 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 privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations.
PSYCHOLOGIST-CLIENT SERVICE AGREEMENTPsychologist-Client Service Agreement • October 14th, 2016
Welcome to my practice. 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 privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
Angelica Shiels Psy.D. LLCPsychologist-Client Service Agreement • April 6th, 2022
