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 • 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
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 • 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.
