Jill Krilov, MDPsychiatrist – Patient Services Agreement • June 7th, 2017
Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. A separate document which will be provided for your review contains summary information about the Health Insurance Portability and Accountability Act (HIPPA), a new federal law that provides new privacy protection 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. HIPPA requires that I provide you with a Notice of Privacy Policy (the Notice) for use and disclosure of PHI for treatment, payment and health care 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 at the end of this session. Although these documents are long and
PSYCHIATRIST-PATIENT SERVICES AGREEMENTPsychiatrist-Patient Services Agreement • September 30th, 2022
Welcome to my practice. The Psychiatrist-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.
Psychiatrist-Patient Services AgreementPsychiatrist-Patient Services Agreement • October 2nd, 2020
Welcome to my practice. This document contains important information about my professional services and business policies. It also contains 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. Please bring up any questions you have at your first appointment.
