Enrich Relationship Center of ColoradoTMPsychologist-Client Services Agreement • June 26th, 2021
Welcome to Enrich Relationship Center of Colorado, formerly Sauder Psychology, Inc. This document (the Agreement) contains important information about 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 client rights with regard to the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for the 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 your signature acknowledging that you have been provided with this information. Although these documents are long and sometimes complex, it is very important
Enrich Relationship Center of ColoradoTMPsychologist-Client Services Agreement • November 13th, 2021
Welcome to Enrich Relationship Center of Colorado, formerly Sauder Psychology, Inc. This document (the Agreement) contains important information about 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 client rights with regard to the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for the 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 your signature acknowledging that you have been provided with this information. Although these documents are long and sometimes complex, it is very important
PSYCHOLOGIST-CLIENT SERVICES AGREEMENTPsychologist-Client Services Agreement • January 3rd, 2024
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 covers 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 provided separately from this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that by the end of our initial session I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is important that
PSYCHOLOGIST- CLIENT SERVICES AGREEMENTPsychologist-Client Services Agreement • May 26th, 2020
Welcome to Breakthru Counseling and Consulting, P.C. (“BCC”), the psychological counseling practice of Dr. Quincy L. Warner. This document contains important information about BCC’s 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 (“client”) 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 BCC provide you with a Notice of Privacy Practices (“Notice”) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which accompanies this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that BCC obtain your signature acknowledging that BCC has provided you with this information. Although these documents
Enrich Relationship Center of ColoradoTMPsychologist-Client Services Agreement • September 17th, 2021
Welcome to Enrich Relationship Center of Colorado, formerly Sauder Psychology, Inc. This document (the Agreement) contains important information about 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 client rights with regard to the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for the 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 your signature acknowledging that you have been provided with this information. Although these documents are long and sometimes complex, it is very important
Betsy Mencher, Ph.D. LLCPsychologist-Client Services Agreement • October 29th, 2020
Welcome to the practice. This document (the Agreement) contains important information regarding our 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 client 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 at the end of the session. Although these documents are long and sometimes complex, it is very important that you read them carefully
Enrich Relationship Center of ColoradoTMPsychologist-Client Services Agreement • September 5th, 2022
Welcome to Enrich Relationship Center of Colorado, formerly Sauder Psychology, Inc. This document (the Agreement) contains important information about 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 client rights with regard to the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for the 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 your signature acknowledging that you have been provided with this information. Although these documents are long and sometimes complex, it is very important
PSYCHOLOGIST-CLIENT SERVICES AGREEMENTPsychologist-Client Services Agreement • October 5th, 2021
Welcome to my practice. This document contains important information about my professional services and business polices. Please read it carefully and jot down any questions you might have so that we can discuss them during our initial appointment. When you sign this document, it will represent an agreement between us.
PSYCHOLOGIST-CLIENT SERVICES AGREEMENTPsychologist-Client Services Agreement • August 9th, 2020
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. 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 ne
PSYCHOLOGISTPsychologist-Client Services Agreement • June 20th, 2012
ASSOCIATES IN FAMILY PSYCHOLOGYPsychologist-Client Services Agreement • March 31st, 2023
Please read these documents carefully so that we can discuss any questions you have about our policies and procedures during your session. When you sign this document, it will represent an Agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have acted in reliance upon it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
ADDENDUM TO PSYCHOLOGIST-CLIENT SERVICES AGREEMENTPsychologist-Client Services Agreement • February 18th, 2008
Patients between 12 and 18 years of age who are not emancipated may consent to psychological services subject to the involvement of their parents or guardian unless the psychologist determines that their involvement would be inappropriate. Specifically a patient over age 12 may consent to psychological services if he or she is mature enough to participate intelligently in such services, and the minor patient either would present a danger of serious physical or mental harm to him or herself or others without treatment, or is the alleged victim of incest or child abuse. In addition, patients over age 12 may consent to alcohol and drug treatment in some circumstances. In cases where the parent or guardian has sought medical care and counseling for the minor child’s drug or alcohol related problem, I am required to disclose such information to the parents or guardian even if the minor patient does not consent to such disclosure. Unemancipated patients under 18 years of age and their parent
PSYCHOLOGIST-CLIENT SERVICES AGREEMENTPsychologist-Client Services Agreement • January 6th, 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.
PSYCHOLOGIST-CLIENT SERVICES AGREEMENTPsychologist-Client Services Agreement • August 9th, 2020
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. 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 session. We can discuss any q
PSYCHOLOGIST-CLIENT SERVICES AGREEMENTPsychologist-Client Services Agreement • December 30th, 2021
Welcome, 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 accompanies 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 at the end of your initial intake session (or first session subsequent to the implementation date of April 14, 2003). Although the
PSYCHOLOGIST-CLIENT SERVICES AGREEMENTPsychologist-Client Services Agreement • August 29th, 2020
Welcome to Rittenhouse Psychological Assessments. This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.
