With my signature below I acknowledge that I have read the Therapist-Client Service Agreement, available on the website, and agree to the terms therein.
I. Counseling ServicesII. AppointmentsIII. Professional FeesIV. Billing and PaymentsV. Insurance ReimbursementVI. EmergenciesVii. Limits on ConfidentialityVIII. Professional RecordsIX. Patient RightsX. Minors and Parents
I also acknowledge that I may have a copy of the Notice of Privacy Practices and Patient Rights at my request from my therapist as required by the Health Insurance Portability and Accountability Act (HIPPA). I understand that my healthcare provider is required under federal law to maintain the privacy of my Protected Health Information (PHI), and I understand the circumstances under which my health information can be disclosed. I am aware that I have a right to request restrictions on uses and disclosures of my PHI and that my provider has a right to not agree to such a restriction. I am aware that I have a right to request communication from my provider by alternative means or locations and that my provider has a right to condition the provision of this accommodation. I am aware that I have a right to request access to my PHI and that my provider may deny this access under certain conditions based on his or her professional judgment. I am aware I have a right to request an accounting of disclosures of my PHI after 4/14/2003 and that there are certain circumstances for which my provider is not subject to these disclosures. I authorize my insurance benefited be paid directly to the Provider. I understand that I am financially responsible for any balance. I also authorize information required to process my claims. I understand that I am financially responsible for appointments cancelled with less than 24 hours notice.