Common Contracts
2 similar Patient Services Agreement contracts
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPatient 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.
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENTPatient Services Agreement • June 6th, 2012
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.
