Changes to the Terms of this Notice. This notice is effective 11/6/2019. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx This is to acknowledge that I have received Care and Counseling’s Privacy Notice Name Signature Date 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Appointment Reminders Care and Counseling offers the option to receive an appointment reminder the day prior to your scheduled appointment by email (up to 2 email addresses) and/or by phone (only 1 phone number permitted). If you choose the reminder by phone, you have the option of a text message or a computer-generated voice message. Please select ONE of the following options: PHONE REMINDER (only one type of phone reminder can be provided): Text Message: I authorize Care and Counseling to send text message appointment reminders to me on my provided cell phone number. Text message charges from my cell phone provider may apply. Example of text message: “Do not reply-reminder-You have an appointment MON 01/11 at 4:00 PM – If you have any questions please call us at (000) 000-0000 – Name of Counselor Cell phone number to send text messages to: ( ) -
Changes to the Terms of this Notice. Gladstone Psychiatry & Wellness may change the terms of this notice at any time. Any changes to this notice are available upon request. Detailed Explanation of Consent for Psychiatric Evaluation and Treatment Gladstone Psychiatry and Wellness will only provide treatment to those to consent for this service. The below is an expanded explanation of the Consent to Medical Care described on page one.
Changes to the Terms of this Notice. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Changes to the Terms of this Notice. Gladstone Psychiatry & Wellness may change the terms of this notice at any time. Any changes to this notice are available upon request. Patient Acknowledgment - Receipt of Notice of Privacy Practices (Initial) I have been provided a copy of the notice of Privacy Practices for Gladstone Psychiatry and Wellness, LLC. (Initial) I have been provided the opportunity to discuss these policies with Gladstone Psychiatry staff, including my clinician, and I understand that I may ask questions about them at any time in the future.
Changes to the Terms of this Notice. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request on our website, and we will mail a copy to you. This notice is effective: March 2021 STOP LOSS INSURANCE POLICY Alliant Health Plans, Inc. 000 X. Xxxxx Street Dalton, Georgia 30722 (A Georgia Insurance Corporation herein called Alliant) This Policy will be construed under the law of the jurisdiction in which it is delivered. In consideration of premium payments by the Insured in the amounts and at times provided, Xxxxxxx agrees with the Insured to provide insurance following the Policy terms. For the purpose of effective dates and termination dates under this Policy, all days begin and end at midnight. This Policy is non- participating. In Witness Whereof, Alliant Health Plans, Inc. has signed this Policy in Dalton, Georgia. Xxxx Xxxxx, President, and CEO, Alliant Health Plans, Inc. Alliant Health Plans, Inc. 000 X. Xxxxx Street Dalton, Georgia 30722 Section 1. Declarations STOP LOSS INSURANCE POLICY FOR: INSURED: POLICY EFFECTIVE DATE: See “Plan Sponsor” listed in Stop Loss Application See “Effective Date” listed in Stop Loss Application DATE OF ISSUE: See Stop Loss Application Attach a copy of the Final Quote
Changes to the Terms of this Notice. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. Other Instructions for Notice • Effective Date of this Notice: 10/15/2018 • Privacy official: o Xxxx Xxxxxxx, CEO o Xxxx@xxxxxxx.xxx o 000 Xxxx Xx. Xxxxxxx Xxxxxx, Xx. Xxxxx, Xxxxxxxxx 00000 o (000) 000-0000 • We never market or sell personal information • We will never share any service records without your written permission; excluding government entities entitled to the information File a complaint if you feel your rights are violated • You can complain if you feel we have violated your rights by contacting the privacy official listed above. • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 000 Xxxxxxxxxxxx Xxxxxx, X.X., Xxxxxxxxxx, X.X. 00000, calling 0-000-000-0000, or visiting xxx.xxx.xxx/xxx/xxxxxxx/xxxxx/xxxxxxxxxx/. • We will not retaliate against you for filing a complaint. Initial Here Sign and Return to CDI Self-Directed Services Participant Agreement THIS AGREEMENT is made effective on , by and between CDI (Consumer Directions, Inc.) as the Financial Management Services (FMS) Entity and , Participant Employer or Representative. (Participant Name or Managing Party) WITNESSETH: That in consideration of the mutual agreements to be kept and performed on the part of both parties as identified, respectively as stated:
Changes to the Terms of this Notice. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request from our business office. - We never market or sell personal information. - This Notice is effective as of November 15, 2013. Our Privacy Officer is: Xxxx Xxxxx-Xxxxxxx 000 Xxxxxxxx, Xxxxx 0000 Xxx Xxxx, Xxx Xxxx 00000 (#212-337-5760) xxxxx@xxxxxxxxxxx.xxx VillageCare Rehabilitation and Nursing Center Effective Date: October 2021 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT FORM I, _ , the Resident, acknowledge and agree that I have received a copy of VillageCare Rehabilitation and Nursing Center’s Notice of Privacy Practices. Resident Signature Date Print Name of Resident’s Relationship to Resident Legal/Designated Representative Signature of Resident’s Date Legal/Designated Representative (If applicable) Witness Date
Changes to the Terms of this Notice. The DBT Center may change the terms of this notice, and the changes will apply to all information held about you. The new notice will be available upon request. This notice was published and becomes effective on or before September 1, 2018. DBT CENTER OF XXXXXXXX Client Portal, Text, and Email Messaging Consent Notification isk Factors and Responsibilities Among general text/email messaging risks are the following: ● Text/email messages can be immediately broadcast and received by many unintended recipients ● Recipients can forward client text/email messages to others without the original sender’s permission or knowledge ● Users can easily misaddress client text/email messages ● Client portal/text/email messages are easier to falsify than handwritten or signed documents ● Backup copies of client portal/text/email messages may exist even after the sender/recipient has deleted their copy ● Clients who send/receive client portal/text/email messages from their place of employment risk having their employer read their client portal/text/email messages The DBT Center Procedures: ● Client portal/text/email messaging communication between a client and DBT Center personnel containing information pertaining to the client’s diagnosis and/or treatment may be included in the client’s medical record. ● Clients should not use client/portal/text/email messaging in an emergency because the DBT Center cannot guarantee that any particular client portal/text/email message will be read and responded to immediately. ● The DBT Center will use reasonable means to protect the security and confidentiality of client portal/text/email message information. Because of the risks outlined above, the DBT Center cannot guarantee the confidentiality and security of client portal/text/email message communication. ● The DBT Center may forward client portal/text/email messages amongst office personnel as necessary for diagnosis, treatment, and reimbursement. The DBT Center will not forward the client portal/text/email message outside of office personnel without the consent of the client and following established consent and confidentiality procedures excluding emergency situations and limits to confidentiality.. ● The DBT Center cannot guarantee a response to a client-initiated client portal/text/email message. ● Because some medical information is so sensitive that unauthorized disclosure can be very damaging, clients should not use client portal/text/email messaging for communications concer...
Changes to the Terms of this Notice. We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request on our website, and we will mail a copy to you. This Notice is effective: March 2021 STOP-LOSS AGREEMENT ATTACHMENT To be attached and made a part of the Administrative Services Agreement Effective: By and between and ALLIANT HEALTH PLANS, INC. and ALLIANT HEALTH PLANS, INC. The Plan Sponsor’s Eligibility, Participation, and Contributions Requirement are as follows:
Changes to the Terms of this Notice. We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site. Effective Date: April 14, 2020 Privacy Official: Xxxxxxx Xx, MD, 000-000-0000, xxxxxx@xxxxxx.xxx
