Materna Psychological Services, PC 724-346-4510Psychologist-Patient Services Agreement • April 15th, 2022
PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPsychologist-Patient Services Agreement • May 13th, 2014
Welcome to our 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 available in my waiting room, 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 tha
Paul Beljan, PsyD, ABPdN, ABN Vanessa Berens, PhD Casey Heinsch, MAS, LAMFT Jodie Graham, MSPsychologist-Patient Services Agreement • August 30th, 2021
Dana A. Max, Psy.D., P.C.Psychologist-Patient Services Agreement • December 30th, 2022
ContractPsychologist-Patient Services Agreement • August 3rd, 2020
Welcome to our practice. This document (the Agreement) contains important information about our professional services and business policies. It also contains summary information about the Health
Psychologist-Patient Services AgreementPsychologist-Patient Services Agreement • November 6th, 2020
This document (the Agreement) 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 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 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, 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 at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before yo
PSYCHOLOGIST - PATIENT SERVICES AGREEMENTPsychologist - Patient Services Agreement • February 7th, 2023
Welcome to Aprioris Psychological Health Services, P.C. 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 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 at the end of this session. Although these documents are long and sometimes complex, it is very
Psychologist-Patient Services AgreementPsychologist-Patient Services Agreement • April 20th, 2020
This Agreement 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) 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, 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 important that you read them carefully. We can discuss any questions you have. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless
Richard A. Van Haveren, Ph.D., PC Licensed PsychologistPsychologist-Patient Services Agreement • August 7th, 2023
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 at the end of this session. Although these documents are long and sometimes complex, it is very important that y
TEL: 919-876-1313Psychologist-Patient Services Agreement • January 13th, 2022
PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPsychologist-Patient Services Agreement • July 13th, 2022
Welcome to my practice. This document (the Agreement) contains important information about my professional services and business practices. 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 purposes 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. 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.
PSYCHOLOGICAL HEALTH ASSOCIATES, PA PSYCHOLOGIST-PATIENT SERVICES.Psychologist-Patient Services Agreement • March 7th, 2010
Welcome to my practice. I am happy to have you as a client. 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 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.
PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPsychologist-Patient Services Agreement • February 5th, 2014
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 posted in the waiting area, 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. We
PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPsychologist-Patient Services Agreement • February 26th, 2013
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. Although these documents are long and sometimes complex, it is very important that you read them carefully befo
PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPsychologist-Patient Services Agreement • March 19th, 2008
Welcome to the clinical practice of Dr. Tamsen Thorpe, a Licensed Psychologist. 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.
ContractPsychologist-Patient Services Agreement • January 29th, 2022
Welcome to our practice. This document (the Agreement) 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 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/assessment, 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, 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.
PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPsychologist-Patient Services Agreement • December 28th, 2019
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. 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
PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPsychologist-Patient Services Agreement • June 19th, 2022
Welcome to Psychology and Beyond! Our core values celebrate compassion, inclusivity, and connectedness. Our mission as a psychotherapy practice is to provide caring, culturally-sensitive, and effective care that helps you to achieve your highest potential, provides you with clarity and increased self-awareness, and eventually leads to meaningful life change. This document contains important information about professional services and business policies at Psychology and Beyond, LLC. Please read it carefully and write down any questions you might have so that you can discuss them with your psychologist at your next meeting.
HIGH PLAINS PSYCHOLOGICAL ASSESSMENT CENTER, LLCPsychologist-Patient Services Agreement • September 26th, 2018
Lou Eckart, Ph.D. Licensed Clinical PsychologistPsychologist-Patient Services Agreement • December 31st, 2014
Fredric Provenzano, Ph.D., NCSPPsychologist-Patient Services Agreement • June 22nd, 2021
Welcome to my practice. This document (the Agreement) 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 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 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, 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 at the end of this session. Although these documents are long and sometimes complex, it is very important that you read
Leslie G. Cohn, Ph.D., P.L.L.C.Psychologist-Patient Services Agreement • March 13th, 2017
Welcome to my practice. I am a licensed psychologist practicing as a sole proprietor in the office suite known as First Hill Psychological Services. 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
SIGNATURE PAGE PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPsychologist-Patient Services Agreement • September 19th, 2016
Please do not sign this document if all of these statements are not true and accurate for you. Your signature further authorizes Dr. Pastore to release any medical or other information necessary to process insurance claims, in accordance with HIPAA regulations, and it also authorizes your insurance company or any government agency to pay medical benefits directly to Vincent L. Pastore, Ph.D. or any of Dr. Pastore’s agents.
PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPsychologist-Patient Services Agreement • August 17th, 2009
Welcome to my practice. I am pleased to have the opportunity to work with you. As we begin our work together, it is important that we have a shared understanding of what we can expect from each other. 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 you were also given today, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledgin
PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPsychologist-Patient Services Agreement • January 23rd, 2019
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. The law requires that I obtain your signature acknowledging that I have provided you with this information. I can discuss any questions you have about the procedures at any time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied an
Jonathan S. Abramowitz, Ph.D., ABPPPsychologist-Patient Services Agreement • June 29th, 2010
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and ask me about anything that isn’t clear to you. I will ask you to sign a separate statement indicating your understanding and agreement with these terms and conditions. You may revoke this agreement in writing at anytime.
Cerio & Cerio Psychologists, P.A. P.C.Psychologist-Patient Services Agreement • December 28th, 2019
This document (the Agreement) 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 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 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, 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 at the end of this visit. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can di
David M. Brooks Ph.D., FIPAPsychologist-Patient Services Agreement • May 13th, 2021
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 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 services. A Separate “Privacy Notice” explains HIPAA and its application to your personal health information in greater detail.
Jill T. Silverman, Ph.D.Psychologist-Patient Services Agreement • October 17th, 2013
Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. When you sign this document, it will also 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 taken action in reliance on 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.
Bruce D. Kobal, PhDPsychologist-Patient Services Agreement • November 19th, 2020
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 at the end of this session. Although these documents are long and sometimes complex, it is very important that y
PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPsychologist-Patient Services Agreement • July 7th, 2010
Welcome to our 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 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. 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 questions you have about the procedures at that time. Whe
PSYCHOLOGIST-PATIENT SERVICES AGREEMENTPsychologist-Patient Services Agreement • July 11th, 2013
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. We can discuss any questions you have about the proce
JAMES HICKEY, PSY.D. LICENSED PSYCHOLOGIST 17 HENSHAW STREET,Psychologist-Patient Services Agreement • June 30th, 2024
Welcome to my practice! This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.
Psychologist-Patient Services AgreementPsychologist-Patient Services Agreement • August 23rd, 2014
Welcome! This document contains important information about my professional services and business policies. This document also contains a brief summary of 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). In compliance with HIPAA, I am also providing you with a Notice of Privacy Practices which explains this in much greater detail. It is very important that you read this document carefully, and we can discuss any questions you have at any time. After reviewing this information, please sign this form, which constitutes an agreement between us. You may revoke this Agreement in writing at any time.
Policies, Procedures, and Informed ConsentPsychologist-Patient Services Agreement • May 3rd, 2016
