Standard Contracts
Psychotherapist-Patient Services AgreementPsychotherapist-Patient Services Agreement • August 29th, 2020
This information is designed to help you understand the therapeutic process and the specifics of my counseling practice. It can feel overwhelming to begin the process of therapy, and this document is to help outline the specifics of what we do in the counseling office. It is important that you have a clear idea of how we will work together, and so after we go over this document, I will ask you to sign the agreement, stating that you have understood the information contained here. When you sign this document, it will represent an agreement between us. Please ask if you have any questions about this document or the therapy process, now or in the future.
Psychotherapist-Patient Services AgreementPsychotherapist-Patient Services Agreement • July 19th, 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 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 for treatment, payment and health care operations. The Notice, which is given with 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
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPsychotherapist-Patient Services Agreement • September 15th, 2022
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
Deborah Bloome, Psy.D., P.A. PY5484Psychotherapist-Patient Services Agreement • June 6th, 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 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
Psychotherapist-Patient Services AgreementPsychotherapist-Patient Services Agreement • October 3rd, 2014
Welcome to my practice! This document (the Agreement) contains important informa- tion about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA),
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPsychotherapist-Patient Services Agreement • March 18th, 2022
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
THE CHRYSALIS GROUP INC.Psychotherapist-Patient Services Agreement • October 28th, 2020
Welcome to my practice. This 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. In addition, The Health Insurance Portability and Accountability Act (HIPAA), a new federal law, requires that I provide you with a Notice of Privacy Practices and that I obtain your signature acknowledging that I have provided you with this information. Those Privacy Practices appear at the end of this document and constitute a part of this agreement. You will receive a copy to keep at the end of our first session.
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPsychotherapist-Patient Services Agreement • October 28th, 2020
This description of my professional services and business policies should answer most questions you may have. Please feel free to ask any unanswered questions and to discuss other concerns you may have as the need arises. This Agreement 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 describing these protections and rights. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail.
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPsychotherapist-Patient Services Agreement • August 3rd, 2020
Welcome to our practice. This document (the Agreement) contains important information about our professional services and business policies. When you sign the Agreement, it will represent an agreement between us. (Note: You will sign this Agreement on the Billing and Insurance Information page of the paperwork.) You may revoke this Agreement in writing at any time. That revocation will be binding on me 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 any financial obligations you have incurred.
Michele R. Russell, Ph.D. Brookwood Center for Psychotherapy, LLCPsychotherapist-Patient Services Agreement • November 17th, 2023
This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portabili- ty 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 Agree- ment, 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 com- plex, it is very important that you read them caref
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPsychotherapist-Patient Services Agreement • December 10th, 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 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
ContractPsychotherapist-Patient Services Agreement • June 21st, 2017
Ryan Long, LICSWPsychotherapist-Patient Services Agreement • May 16th, 2017
Welcome. This document contains important information about my professional services and business policies. Although this document is long, it is very important that you read it carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us.
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPsychotherapist-Patient Services Agreement • November 17th, 2017
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
Jessie Garcia, Ph.D. Licensed PsychologistPsychotherapist-Patient Services Agreement • November 21st, 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
Center for Healing, LLCPsychotherapist-Patient Services Agreement • October 7th, 2019
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPsychotherapist-Patient Services Agreement • July 13th, 2016
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 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
ContractPsychotherapist-Patient Services Agreement • August 9th, 2020
Katherine A. Prakken, Ph.D. 104 S. Estes Dr. Suite 301W Chapel Hill, NC 27514Psychotherapist-Patient Services Agreement • November 18th, 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 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 you read them car
Laura Struhl, Ph.D.Psychotherapist-Patient Services Agreement • March 6th, 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). This federal law provides new privacy protections and new patient rights regarding the use and disclosure of your Protected Health Information (PHI). HIPAA requires that I provide you with a Notice of Privacy Practices accompanying this document. The law requires that I obtain your signature acknowledging that I have provided you with this information and that you agree/consent to let me use your information as specified in the Notice. Although these documents are long and sometimes complex, it is essential that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have acted in reliance on it
PSYCHOTHERAPIST-‐PATIENT SERVICES AGREEMENT [NEW YORK]Psychotherapist-Patient Services Agreement • November 13th, 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 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 the
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT [NEW YORK]Psychotherapist-Patient Services Agreement • May 12th, 2015
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
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPsychotherapist-Patient Services Agreement • September 24th, 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 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. When you sign this
Ann Dunnewold, Ph.D.Psychotherapist-Patient Services Agreement • September 25th, 2022
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 complex, it is very important that you read them carefully now. We can di
ContractPsychotherapist-Patient Services Agreement • January 22nd, 2014
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT AND INFORMED CONSENTPsychotherapist-Patient Services Agreement • April 12th, 2022
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. There is a 2013 addendum to the notice that HIPPA requires I give you, which mostly has to do with my responsibility to notify you if your information has been breached (similar to what a credit card company has to do if your credit card information has been compromised). The HIPPA Notice, which is included in this Agreement, explains HIPAA and its application to your
ContractPsychotherapist-Patient Services Agreement • April 5th, 2018
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 new 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 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 (The Acknowledgment Notice) 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 procedures. Whe
LESLIE H. KERN, Ph.D. CLINICAL PSYCHOLOGISTPsychotherapist-Patient Services Agreement • October 15th, 2022
Welcome to my practice. This document contains important information about my professional services and business policies. Following this document is a second document that 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. 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. Although this docwnent is long and sometimes complex, it is necessary for me to provide you with this information in order to comply with federal regulations. We can discuss any questions you have about thi
ANDREW MCGARRAHAN, Ph.D. CLINICAL PSYCHOLOGYPsychotherapist-Patient Services Agreement • January 29th, 2019
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 important that you read them carefully before our next s
JACKIE TWITCHELL, PSY.D.Psychotherapist-Patient Services Agreement • December 6th, 2021
Welcome to my practice. This 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 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. We can discuss any questions you have about the procedures. When you sign this document, it will also represent an agreement
GARY S. KATZ, PH.D. A PROFESSIONAL PSYCHOLOGY CORPORATION GARY S. KATZ, PH.D. 509 MARIN STREET SUITE 236 CLINICAL PSYCHOLOGISTPsychotherapist-Patient Services Agreement • January 15th, 2015
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPsychotherapist-Patient Services Agreement • May 24th, 2022
This document (the Agreement) contains important information about the therapist’s 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 the therapist 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 included in your intake packet, explains HIPAA and its application to your personal health information in greater detail. The law requires that the therapist obtain your signature acknowledging that the therapist has provided you with this information by the end of our first session. We can discuss any questions you have about this ag
Laura Schwerin, Ph.DPsychotherapist-Patient Services Agreement • February 3rd, 2022
The following answers some important and frequently asked questions concerning my practice. Please read this information carefully and let me know if there is any part you do not understand. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and patient rights concerning the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. “PHI” refers to individually identifiable health information. PHI includes any identifiable health information received or created by my office or me. 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 is available on my website (Privacy Policy) or I will give you a printed copy upon request. This Agreement, explains HIPAA and its application to your personal health in
ContractPsychotherapist-Patient Services Agreement • October 26th, 2020
Welcome to Universal Counseling, LLC. 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). HIPAA requires that Universal Counseling, LLC 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 Universal Counseling, LLC obtain your signature acknowledging that you have been provided this information. Although these documents are long and sometimes complex, it is very important that you read them carefully, and we can discuss any qu
Drs. Lapporte, Wright, & Associates, P.C.Psychotherapist-Patient Services Agreement • March 1st, 2020
