Nancy McReynolds, Ph.D., LPC, LADC, CEDS, ATR Licensed Alcohol & Drug Counselor – Certified Eating Disorders Specialist Licensed Professional CounselorTherapist-Patient Services Agreement • November 29th, 2020
Welcome to my practice. This agreement contains important information about my professional services and business policies. 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. A copy of such privacy notice is posted in the waiting room. A printed copy will be provided at your request. The law requires that I obtain your signature acknowledging that I have provided you with this information.
THERAPIST-PATIENT SERVICES AGREEMENTTherapist-Patient Services Agreement • June 15th, 2017
Welcome to my practice. This document contains 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 rights for you as a patient with regards to the use and disclosure of your Protected Health Information (PHI). 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, 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 before the end of today’s session.
THERAPIST-PATIENT SERVICES AGREEMENTTherapist-Patient Services Agreement • December 30th, 2019
Welcome to Renz Counseling. This agreement contains important information about our professional services and business policies. Once you sign this, it will constitute a binding agreement between us. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patients rights regarding the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment and health care operations.
THERAPIST-PATIENT SERVICES AGREEMENTTherapist-Patient Services Agreement • August 18th, 2024
Welcome to Brave Minds Psychological Services (BMPS). 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.
THERAPIST-PATIENT SERVICES AGREEMENTTherapist-Patient Services Agreement • April 21st, 2020
This document contains 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 rights for you as a patient with regards to the use and disclosure of your Protected Health Information (PHI). 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, 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 before the end of today’s session.
THERAPIST - PATIENT SERVICES AGREEMENT GROUP THERAPYTherapist - Patient Services Agreement • December 9th, 2011
This document (AKA “the Agreement”) contains important information about the professional services and business policies of the Center for Valued Living, PLLC and me, your therapist. 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 you are provided with a Notice of Privacy Practices (AKA “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 you have provided with this information. Your signature on this form will indicate that you have received and rea
LAURA J. DALLALIO-CROTTY, MS, LMHC, LPCC Therapist-Patient Services AgreementTherapist-Patient Services Agreement • August 17th, 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 new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and healthcare 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 healthcare operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your PHI 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 before our s
THERAPIST-PATIENT SERVICES AGREEMENT & POLICIESTherapist-Patient Services Agreement • February 27th, 2023
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 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
THERAPIST- PATIENT SERVICES AGREEMENTTherapist-Patient Services Agreement • November 2nd, 2017
Welcome to Focused Behavioral Health, LLC. 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 our first session. Although these documents are long and sometimes complex, it is very impo
THERAPIST-PATIENT SERVICES AGREEMENTTherapist-Patient Services Agreement • March 25th, 2020
Welcome to Clinical Psychotherapy & Consultation, LLC, a private practice offering psychological and consulting services. Dr. Janet Bloodgood, a New Jersey Licensed Psychologist (#5129), is the President/CEO and Clinical Director of Clinical Psychotherapy & Consultation, LLC. This document contains important information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights regarding the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.
Therapist-Patient Services AgreementTherapist-Patient Services Agreement • December 10th, 2020
Welcome to my practice. This agreement contains important information about my professional services and business policies that have important implications for any services that are provided to you. I make myself available to assist the family with agreement to the below provisions. If you have questions or concerns about any of the below provisions, you are encouraged to seek input from legal counsel or direct concerns directly to the Court. Your signature below indicates your agreement to participate in the professional’s process within the identified contractual agreement.
Therapist – Patient Services AgreementTherapist – Patient Services Agreement • June 16th, 2020
My signature below indicates that I have received a copy of the THERAPIST-PATIENT SERVICES AGREEMENT (updated January 2020) and I agree to abide by its terms during our professional relationship.
Therapist-Patient Services AgreementTherapist-Patient Services Agreement • December 19th, 2017
Welcome to my practice. This agreement contains important information about my professional services and business policies.
Clinical Social WorkerTherapist-Patient Services Agreement • May 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 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 will be given to you in addition 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 Notice of Privacy Practices at the end of this session. Although these documents are long and sometimes com
THERAPIST-PATIENT SERVICES AGREEMENTTherapist-Patient Services Agreement • October 5th, 2021
The Therapist-Patient Services 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 regarding the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. You may revoke this Agreement in writing at any time.
Ventura, CA 93003Therapist-Patient Services Agreement • August 11th, 2010
This document (the Agreement) contains important information about our professional services and business policies. A Separate “Privacy Notice” explains the Health Insurance Portability and Accountability Act (HIPAA), and its application to your personal health information in greater detail. The law requires that your therapist obtain your signature indicating that he/she has provided you with this information.
THERAPIST-PATIENT SERVICES AGREEMENTTherapist-Patient Services Agreement • February 5th, 2021
Welcome to my practice! The Therapist-Patient Services 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 regarding the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. You may revoke this Agreement in writing at any time.
ContractTherapist-Patient Services Agreement • October 8th, 2014
Welcome to my private 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 (HIPPA), a federal law that provides new privacy protections and new patients’ 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. HIPPA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and healthcare operations. The Notice, which is attached to this Agreement, explains HIPPA 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
ContractTherapist-Patient Services Agreement • December 30th, 2019
Please initial each of the following policies to indicate that you have read, understand, and agree to them as they are fully stated on the previous pages. Please sign your full name at the bottom of this page to indicate that you have read, understand, and accept the terms of this Therapist-Client Services Agreement. Please keep the preceding pages of the Agreement for your records.
THERAPIST-PATIENT SERVICES AGREEMENTTherapist-Patient Services Agreement • July 10th, 2020
Welcome to my practice. The Therapist-Patient Services 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. You may revoke this Agreement in writing at any time.
