Cathexis Tucson, LLC. - Psychotherapy and Counseling Service Agreement (Includes Client Rights and Responsibilities, HIPAA Privacy Statement, Consent for Telehealth Services and Release of Information Consent)Psychotherapy and Counseling Service Agreement • January 28th, 2021
By signing this Agreement, you are consenting to enter a therapeutic relationship with Cathexis. You can revoke this Agreement at any time. If you decide to end the treatment relationship, please consult with your therapist about your desire to do so. That revocation will be binding on Cathexis, unless this agency has taken action in reliance on it, if there are obligations imposed on this agency by your health insurance in order to process or substantiate claims made under your policy or if you have not satisfied any financial obligations you have incurred. This consent to treat will expire 12 months from the date of signature, unless otherwise specified.
Psychotherapy and Counseling Service Agreement and Client RightsPsychotherapy and Counseling Service Agreement • November 25th, 2019
This document also contains 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 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 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 and discuss and questions or concerns with your therapist.
