OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • February 10th, 2023
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • March 21st, 2022
This document contains important information about the professional services and business policies of Horizon Psychological Services (HPS). It is important that you read it carefully and jot down any questions you might have so that they can be discussed with your treating professional. When you sign this document, it will represent an agreement between you and HPS.
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • December 29th, 2021
Welcome to Premier Psychological Counseling & Consulting & Premier TMS (PremierPCC/TMS). This document contains important information about our clinic’s professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our first meeting. When you sign this document, it will represent an agreement between us.
Outpatient Services Agreement for Collateral ParticipantsOutpatient Services Agreement • May 6th, 2009
Dr.Outpatient Services Agreement • January 14th, 2019
Outpatient Services AgreementOutpatient Services Agreement • October 7th, 2019
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 purposes of treatment, payment, and health care operations. HIPAA requires that I provide you with a New York Notice Form that 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 complex, it is very important that you read them all before our next session. Please note any questions that you might have so that we can discuss them further. After reading this outpatient services a
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • November 10th, 2016
Welcome to Spectrum Transformation Group. This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so that you and your provider can discuss them at your next meeting. When you sign this document, it will represent an agreement between you and your provider.
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • May 21st, 2023
This OUTPATIENT SERVICES AGREEMENT (“Agreement”) is made by and between Tiffany Mehling, LCSW d/b/a Persist Psych, a sole proprietorship (the “Practice or Persist Psych”), Practice’s other clinical practitioners (the “Practitioner(s)”), and you (the “Patient”) of the Practice (individually, a “Party”, and collectively, the “Parties”), effective upon the date this Agreement is signed by the Patient.
OUTPATIENT SERVICES AGREEMENT/INFORMED CONSENTOutpatient Services Agreement • June 22nd, 2023
This document contains important information about my professional services and business policies. I look forward to discussing any questions with you so that I can be clear on the policies and expectations.
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • June 9th, 2015
Welcome to the Counseling and Diagnostic Center of Woodfield, Ltd. This document contains important information about the professional services and business policies of this clinic. Please read it carefully and note any questions you might have so that we can discuss them at our meeting. By signing below you agree to the policies described herein. Upon the completion of our first session, I will request that you sign this document, please review it accordingly prior to the session.
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • October 11th, 2023
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • August 9th, 2020
Behavioral health services are provided by licensed psychologists or licensed masters-level therapists at Savannah Behavioral Pediatrics, LLC.
Outpatient Services AgreementOutpatient Services Agreement • July 24th, 2014
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 purposes of treatment, payment, and health care operations. HIPAA requires that I provide you with a Indiana Notice Form that 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 complex, it is very important that you read them all before our next session. Please note any questions that you might have so that we can discuss them further. After reading this outpatient services ag
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • February 23rd, 2020
Your participation in your loved one’s treatment is important, and is sometimes essential to the success of the treatment. This document is to inform you about the risks, rights and responsibilities of your participation as a collateral participant.
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • February 25th, 2016
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • April 28th, 2016
Welcome to our practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions that you might have so that we can discuss them at our next meeting. Once you sign this, it will constitute a binding agreement between us.
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • August 19th, 2020
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting.
Outpatient Services AgreementOutpatient Services Agreement • July 20th, 2021
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 privacy protections and 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 New York Notice Form that 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 complex, it is very important that you read them all before our next session. Please note any questions that you might have so that we can discuss them further. After reading this outpatient services agreement, yo
OUTPATIENT SERVICES AGREEMENT/INFORMED CONSENTOutpatient Services Agreement • August 9th, 2020
This document contains important information about our professional services and business policies. We look forward to discussing any questions with you so that we can be clear on the policies and expectations.
Child/Adolescent Outpatient Services AgreementOutpatient Services Agreement • May 13th, 2020
Prior to beginning treatment, it is important for you to understand my approach to child therapy and agree to some rules about your child’s confidentiality during the course of his/her treatment. The information herein is in addition to the information contained in the Patient-Therapist Agreement. Under HIPAA and my Ethics Code, I am legally and ethically responsible to provide you with informed consent. As we go forward, I will try to remind you of important issues as they arise.
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • January 29th, 2022
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • April 17th, 2020
Welcome to my practice. This document contains important information about my professional services and business policies. It is important that you read it carefully and jot down any questions you might have so that we can discuss them at our first meeting. When you sign this document, it will represent an agreement between us.
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • October 17th, 2016
Welcome to Amanda Kracen, Ph.D., LLC. This Outpatient Services Agreement (the “Agreement”) contains important information about my professional services and business policies. Please read it carefully and write down any questions you might have so that we can discuss them. When you sign this Agreement, it will represent a legal contract between us.
COUNSELINGOutpatient Services Agreement • October 13th, 2020
A collateral is usually a spouse, family member, or friend, who participates in therapy to assist the identified patient. The collateral is not considered to be a client and is not the subject of the treatment. Social Workers have certain legal and ethical responsibilities to client, and the privacy of the relationship is given legal protection.
Deborah L. Conley, LCSWOutpatient Services Agreement • November 7th, 2020
Welcome to the counseling practice of Deborah L. Conley, Ltd. This document contains important information about the professional services and business policies of my practice. Please read it carefully and note any questions you might have so that we can discuss them at our meeting. I will ask you to sign this during our first session.
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • February 25th, 2020
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions that you might have so that we can discuss them at our next meeting. Once you sign this, it will constitute a binding agreement between us.
Welcome to the Mary Rackham Institute (MARI) OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • April 20th, 2020
The purpose of this document is to explain important aspects of professional services and policies at MARI and to ensure that patients have a clear understanding of the goals and structure of our work together. Please read it carefully and ask MARI staff any questions that you might have about our
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • May 22nd, 2017
chotherapeutic treatment. Your participation is important, and is sometimes essential to the suc- cess of the treatment. This document is to inform you about the risks, rights and responsibilities of your participation as a collateral participant.
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALS Lorraine Saldivar, M.A., LPC #76703, LCDC #12433Outpatient Services Agreement • October 5th, 2018
Thank you for accepting the invitation to assist in the psychotherapeutic treatment of _______________________________ (client name) with Lorraine Saldivar, M.A. LPC, LCDC. Your participation is important, and is sometimes essential to the success of the treatment. This document is to inform you about the risks, rights and responsibilities of your participation as a collateral participant in therapy.
SALEM PSYCHOLOGICAL ASSOCIATES, P.A.Outpatient Services Agreement • February 7th, 2014
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 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 and that I obtain your signature acknowledging that I have provided you with this information. Please read this document carefully and let me know if you have any questions.
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALSOutpatient Services Agreement • February 20th, 2019
ELIZABETH PIERCE, PH.D. LICENSED PSYCHOLOGISTOutpatient Services Agreement • March 7th, 2021
Welcome. This document contains important information about my professional services and business policies. Providing this information to you is considered a standard and ethical part of practice. This form also contains information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law regarding health care records. This form is somewhat lengthy, but it is important that you review it carefully, and raise any questions with me that you might have. After the initial session, keep this document handy, as you may want to refer to it later.
SALEM PSYCHOLOGICAL ASSOCIATES, P.A.Outpatient Services Agreement • June 25th, 2018
This is important information about our services and business policies, and the Health Insurance Portability and Accountability Act (HIPAA), a federal law which provides privacy and patient rights for your Protected Health Information (PHI).
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • March 21st, 2019
Welcome to Chosen, PLLC! The purpose of this document is to provide you with information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA). HIPAA provides new privacy protections and patient rights with regard to the use and disclosure of “Protected Health Information” (PHI) used for the purpose of treatment payment of services, and healthcare operations. Please read it carefully and jot down any questions you might have so we can discuss them in your appointment. When you sign this document, it will represent an agreement between us.
OUTPATIENT SERVICES AGREEMENTOutpatient Services Agreement • September 26th, 2022
Welcome to Karen Muehl Counseling, PLLC. This Outpatient Services Agreement (the “Agreement”) contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this Agreement, it will represent a legal contract between us.
