Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center
|
|
- Alexander Maxwell
- 8 years ago
- Views:
Transcription
1 Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center Intensive Outpatient Program Participant Handbook
2 Table Of Contents: Welcome..... Page 1 Introduction. Page 1 Staff Page 1 Informed consent... Page 1 What to expect.. Page 2 Appointments.... Page 2 Fees and Payment... Page 2 Confidentiality... Page 2 Consultation and supervision. Page 3 Treatment records. Page 3 Emergency Services.. Page 3 Signed Consent for treatment Page 3 Notice of Privacy Practices.. Page 5 What is this notice...page 5 Some useful definitions...page 5 How do we use and disclose... Page 5/6 Other ways health information can be disclosed. Page 6 Privacy rights. Page 6/7 Our duties to you.... Page 7 Questions or complaints Page 8 Group information. Page 10 Group rule.... Page 10 Schedule Page 10 Phase Transitions & Graduation. Page 10 Transportation. Page 10 Drug Testing.. Page 11 Calling out Page 11 Emergency Procedures. Page 11
3 Welcome to the Family Willows Participants of the Family Willows Intensive Outpatient Program will work with their treatment team to create an individualized treatment plan that will depend on their unique needs. Treatment includes individual therapy, case management, trauma and addiction psycho-education, and group therapy. Introduction The Family Willows is committed to individualized treatment, discharge and aftercare to meet the complex needs. Our IOP program can last up to 16 weeks, participants will be individually assessed for readiness for discharge or for adjustments in treatment plans. The Family Willows staff with work with you to reduce substance use and harmful behaviors in your life by building skills that will allow you to be more independent and self-sufficient. You will have many opportunities to learn and discuss these principles during the course of treatment. Please ask your treatment team to explain anything you do not understand or answer any questions you may have. Family Willows Staff Meghan Shea, MSW, LICSW, MLADC, Program Manager Emily MacDonald, BA, Intake Coordinator Katie Gordon, BSW, LADC, Treatment Coordinator Michelle Lattime,MS, Treatment Coordinator Ashley Kitchell, Recovery support worker Informed Consent for the Family Willows Intensive Outpatient Program (IOP) Your Rights: As a client of Families in Transition, you have several rights. You have the right to: Decide not to enter intensive outpatient services, decide not participate in specific types of services, and to decide to terminate services at any time. A safe environment, free from emotional, physical, and sexual abuse. Be treated with respect by self, staff, and other clients. Be free from discrimination from self, staff, and other clients, including but not limited to racial, sexual, religious, age, gender, or economic discrimination. Complete and accurate information about your treatment including goals, methods, potential risks and benefits, and progress. Information about the professional capabilities and limitations of any professional involved in your treatment. Receive treatment from trained and qualified professionals. Written information about fees, payment methods, and lengths and duration of sessions and treatment. Be informed about the limits of confidentiality, the situations in which your counselor and/or the agency is legally bound to disclose information to outside persons or agencies, and the types of information that will be disclosed. Know if your counselor will discuss your case with supervisors or peers. Request a summary of your treatment. Request the release of your clinical information to any agency or person that you choose.
4 Be referred to appropriate community services, based on individual needs, as we are able to identify them. If you are asked to leave the program, to know why you are being asked to leave and what conditions you must meet in order to return to Families in Transition. File a grievance with Families in Transition if you feel that any of your rights have been violated. 1 What to expect from the Family Willows IOP: Counseling is a process in which you work with a counselor in order to resolve problems and meet agreed upon goals. Counseling is not like a visit to a medical doctor. Rather, it calls for a very active effort on your part. In order for counseling to be most successful, you will have to work on things that are discussed both during sessions and at home. Counseling can have risks and benefits. Counseling often involves discussing unpleasant aspects of your life and you may experience uncomfortable feelings as a result. However, counseling has also been shown to help individuals resolve specific problems and reduce feelings of distress. Appointments: Sessions are normally 50 minutes and are scheduled based upon your needs. We ask that you be on time for appointments. If you need to cancel or reschedule an appointment, please contact your counselor as soon as possible. If you do not show up for two (2) sessions in a row, your counselor may terminate services. We will bill you for missed appointments that have not been canceled or rescheduled at least 24 hours in advance at your normal session rate. Fees and Payment: We provide services based on a sliding fee scale ranging from no fee to $70 per session. Although we will not refuse services to any eligible person because of an inability to pay, we ask that you attempt to contribute something to the cost of your counseling. Families in Transition does not have agreements with any insurance providers for reimbursement and, as such, you are responsible for the cost of all services provided to you. Payment of fees for services is expected on the day that services are delivered and any balance must be paid in full prior to receiving additional services unless special arrangements are agreed upon with your counselor. Confidentiality: The confidentiality of client records maintained by Families in Transition is protected by federal law and regulations. Generally, we may not say to a person outside of this agency that a client receives services here, or disclose any information identifying a client as an alcohol or other drug abuser. The exceptions to this include (a) with written consent from you, (b) if the disclosure is permitted by court order, (c) the disclosure is made to medical personnel in a medical emergency, or (d) to report suspected child abuse and neglect or suspected elder or incapacitated adult abuse, neglect, or exploitation. In addition, the New Hampshire Department of Health and Human Services Bureau of Community Health Services is authorized to review our records to ensure that we are providing quality services. Violation of the federal law and regulations by this agency is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal guidelines. Federal law and regulations do not protect any information about a crime committed by a client either on Families in Transition property, against any person who works for Families in Transition, or any threat to commit such a crime. (See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for federal laws and 42 CFR part 2 for federal regulations)
5 2 Consultation and Supervision: Each counselor at Families in Transition participates in regular clinical supervision and peer case consultation with clinicians who are bound by the same standards of confidentiality. The goal of this supervision and consultation is to provide the most effective and helpful services to our clients and to continually improve our skills as clinicians. As part of this supervision and consultation, your counselor may request your permission to audio- or videotape sessions with you. We assure you that these tapes will be used only for quality assurance and supervisory purposes. Tapes will be erased after being reviewed. If you do not want your sessions to be taped (in whole or part), you are under no obligation to consent to this request and your eligibility for services will not be affected. Treatment Records: The laws and standards of professional counseling mandate that we keep records of your treatment. You have the right to receive a copy of your record, or we can prepare a summary of your treatment for you instead. Due to the professional nature of these records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we recommend that you arrange to do so in the presence of your primary counselor so that the contents can be discussed. We reserve the right to withhold the release of your records to outside agencies if you have an outstanding balance. Emergency Services: In the event of an emergency when your counselor is not available, please contact the Families in Transition Hotline at (603) or This source of support is available to you 24 hours a day, 7 days a week. Signed Consent for Treatment: Please read the following statement and indicate your agreement by signing below. My counselor and I have agreed that my fee for services will be $ week. If at any time my fee becomes a problem, I will discuss it with my counselor during our session. I have read and/or had explained all of the preceding statements and understand my rights and responsibilities for the services rendered by Families in Transition. I agree to these conditions of my counseling as provided in this agreement. Client Signature Date Counselor Signature Date
6 3 Signed Consent for Treatment: Please read the following statement and indicate your agreement by signing below. My counselor and I have agreed that my fee for services will be $ per week. If at any time my fee becomes a problem, I will discuss it with my counselor during our session. I have read and/or had explained all of the preceding statements and understand my rights and responsibilities for the services rendered by Families in Transition. I agree to these conditions of my counseling as provided in this agreement. Client Signature Date Counselor Signature Date Consent to Record Counseling Sessions: I hereby give consent (initial)/do not give consent (initial) to my counselor at the Families in Transition, Inc. to: videotape (initial if Yes) audiotape (initial if Yes) our counseling sessions. These recordings will be used to aid the counseling process and to gain further understanding of important aspects of the treatment. I have discussed this procedure with my counselor. I understand that refusal to consent to taping will not affect my eligibility for receiving services at this agency. Client Signature Date Counselor Signature Date
7 4 Notice of Privacy Practices What is this notice? This notice was prepared to provide you with an understandable explanation about how we may "use" and "disclose" your "protected health information." Health information is an indispensable part of healthcare treatment, payment and operations; without access to health information, the healthcare system cannot function. A Federal Law called the Health Insurance Portability and Accountability Act (HIPAA), or the Privacy Rule, was created to support your privacy and rights surrounding your health information. We understand that health information about you is very personal. Families in Transition is committed to insuring the privacy and confidentiality of your personally identifiable health information. All employees and volunteers must sign a confidentiality agreement when hired. An informed client is an important ally for us in meeting these goals. We hope you will take the time to read our notice and to call us if you have any questions. Some useful definitions: Protected Health Information ("PHI") - Any information, created by us in any form that identifies and is related to the past, present, or future: 1) Physical or mental health of the individual; 2) Provision of health care to the individual; or 3) Payment for health care provided to the individual. If all personal identifiers have been removed from the information, it is considered "de-identified health information" and may be used more freely than protected health information. "Uses" and "Disclosures" - We use these terms as they are defined in the Privacy Rule. We "use" your protected health information when we examine, review, analyze, or share it within Families in Transition, Inc. We "disclose" your protected health information when we release, transfer, provide access to, or share it in any other way with any other organization or individual, for example to a state agency or to a referring provider. How do we use and disclose your protected health information? The Privacy Rule permits us to use and disclose your "protected health information" (PHI) for treatment, payment, and healthcare operations. Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, require that we ask for your written consent to disclose your protected health information. The following describes in general how we may use or disclose your health information for treatment, payment, and health care operations: Treatment: We may use or disclose your health information to provide and coordinate your treatment. Families in Transition may use or disclose your health information among members of your treatment team or other personnel within Families in Transition. If healthcare providers outside of Families in Transition request your health information, we will ask you for your written consent before sharing the information.
8 Payment: We may use and disclose health information about you so that the services you received from us may be billed for and payment collected. Health Care Operations: We may use and disclose health information about you within Families in Transition to make sure that you receive quality care. For example, we may use health information to review our services, to evaluate the performance of our staff, or to review your records if you file a complaint. 5 What other ways may we use and disclose your health information? Public Health Information (these are required by law): We may use or disclose your health information when necessary to prevent a serious threat to your health or safety or to the health or safety of others. For example, health information may be used or disclosed for an Involuntary Emergency Admission or to report abuse or neglect of minors, elders, or dependent adults. Health Oversight Activities: We may disclose health information to a health oversight agency for them to make sure we are following the law. (Audits, inspections, investigations, or licensure) Emergency Situations: If an emergency happens to you, we may need to release your health information, without your consent, to medical personnel so they can treat you. As Required by Law: We may disclose health information about you in situations not already mentioned when required to do so by federal, state, or local law. Research: We may disclose your health information to researchers when you have agreed to participate in a study. Law Enforcement Activities: We may disclose health information to a law enforcement official for law enforcement purposes when the information is needed to identify or locate a suspect, fugitive, material witness, or missing person; to report a death that may be the result of criminal conduct; to report criminal conduct occurring on our premises; if we receive a court order or subpoena to produce your health information; if a medical examiner requests your health information; or to the State or District Attorney s Office if you are the victim of a crime. Such releases of information will only be made after reasonable efforts to contact you for your authorization. If we cannot contact you, we will obtain legal advice, but we may be required to release your records. What are your privacy rights? The Federal Privacy Rule gives you several new rights with respect to your protected health information (in addition to those rights you already have under state law). Beginning April 14, 2003, you have the following rights to your health information: Right to a Paper Copy of this Notice: You have the right to receive written notice of our privacy practices (That's this document.) If you have received this notice electronically, you have the right to a paper copy if you want it. Right to Request Restrictions: You have the right to ask for further restrictions on the ways in which we use and disclose your protected health information. We are not required to agree to a requested restriction. We will not agree to any request unless we feel that we can fully meet our commitment. Right to Request Confidential Communications: You have the right to ask that we communicate with you in a certain manner or at a certain location. We will make efforts to accommodate reasonable requests. You must make this request in writing.
9 6 Right to Inspect and to Copy: You have the right to see and get a copy of your treatment record or any other protected health information that we keep in a regular paper or electronic file. We may charge you a reasonable fee for copies, consistent with state law. You must make this request in writing. We may ask for a verification of identity as you make these requests. (Note: There are a few situations specified in the Privacy Rule where this right does not apply.) Right to Request an Amendment: You have the right to ask for an amendment of your protected health information. Entries are not deleted from medical records because of legal requirements but may be corrected or amended by the author of the entry. You may request an amendment of your treatment record or other protected health information that we keep in a regular file. You must make this request in writing. If the information is accurate and complete as determined by the author of the entry, we will decline the request for amendment but will include your request and statement of disagreement in your file. Right to Request a List of How We Shared Your Health Information: You have the right to receive a written accounting of the disclosures we have made of your protected health information. This accounting does not include disclosures for treatment, payment or healthcare operations, disclosures authorized by you, and certain other exceptions. You must make this request in writing. Right to Designate a Personal Representative: You have the right to designate a "Personal Representative" to help you exercise your rights concerning your protected health information. This personal representative must be designated in writing, and must show this designation any time he or she wishes to exercise the rights attached to it. New Hampshire State laws apply to the rights and responsibilities of personal representatives. Our duties to you: We are required by law to maintain the privacy of your personal health information, and to give you notice of our legal duties and privacy practices with respect to your protected health information. We are required to abide by the terms of our Privacy Notice currently in effect. We reserve the right to change our privacy practices (that is, to change the ways in which we use or share your protected health information as described in the Notice), so long as the new practices are permitted by the Federal Privacy Rule or other applicable law, and are described in a revised Notice of our privacy practices. We further reserve the right to make any such revised Notice provisions effective for all protected health information we maintain, including information created or received before the effective date of the revised Notice. Revised Notices will be posted in service locations, and will be available on request from Families in Transition.
10 7 Questions or Complaints? If you have a question or believe your privacy rights have been violated, you may request clarification or file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services. Families in Transition s Privacy Officer will assist you with your complaint, if you request such assistance. Privacy Officer Secretary, Dept. Of HHS Families in Transition U.S. Department of Health and Human Services 122 Market Street Office of Civil Rights Manchester, NH Independence Avenue, S.W. Phone: (603) RM 515 F HHH Bldg. Washington, D.C Phone: (202) Toll-Free All complains must be submitted in writing. We will respond to all properly filed complaints. You will not be adversely affected or discriminated against in any way for filing any such complaint.
11 8
12 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I have received a copy of the Families in Transition Notice of Privacy Practices. I understand that Families in Transition has the right to change its Notice of Privacy Practices from time to time and that I may contact Families in Transition at any time to obtain a current copy of the Notice of Privacy Practices. Client Name (Print) Signature of Client/Legal Representative Relationship to Client Date FOR OFFICE USE ONLY PRINT PLEASE I have attempted to obtain the patient s signature on this form, but was not able to for the following reason: Please document the reasons you were unable to obtain the signature. Date: Initials:
13 Group information Family Willows IOP Group Rules: Confidentiality - What is said in group stays in group. Non-judgment - Use I statements. Respect Treat others as you wish to be treated. Participate Actively participate in group. No Cell Phones - Cell phones must be turned off and placed on the table in front of you. You may only have your phone on with the permission of the group for anticipated critical calls. Food Healthy snacks may be brought into group. Junk food and fast food will not be allowed. No alcohol or drugs on FIT property If you are required to take medications during IOP hours, you must provide a doctor s note. Staff request that mothers limit disruption to child care room by not visiting during breaks Schedule: Phase 1 Mondays, Wednesdays, and Fridays 9am 12pm Phase 2 Tuesdays & Thursdays 9am 12pm Childcare will open for drop-off at 8:30am. Please have your child dropped off prior to 9am so that you may join group on time. Phase Transitions & Graduation: Movement from Phase 1 to Phase 2 will be decided based on completion of program goals and your personal goals. When you believe you have completed both the goals of the Phase and your goals for that Phase, you will be asked to submit a request to transition, which you will present to the group for discussion and feedback. Upon the group s and IOP Team s approval, you will be graduated to Phase 2. Graduation from the program as a whole will be determined by accomplishment of program goals and your personal goals. You will submit a request to the group describing your completion of goals and your recovery/aftercare plan. Upon the group s and IOP Team s approval, you will graduate. Transportation: Transportation is an exceptionally limited resource! Thus, we must maintain several strict rules. o Drivers will only wait 3 minutes for you. If you are not out waiting for us or do not come out quickly, we will leave and it will count as a no show for transportation. o You must cancel transportation by 9pm the previous evening. If you do not and do not show, it will count as a no show for transportation. o If you do not show for transportation twice, you will lose transportation services. 10
14 Drug Testing: Drug test results will be discussed at the time of the drug test. It is important to do this so that this tool is focused on supporting your treatment and recovery journey, versus punishment. Drug tests will include urine screens as well as a breathalyzer Thus, drug testing will be conducted during individual counseling and case management sessions. However, if you miss your individual appointments for the week, a drug test will be conducted during group and your results will be discussed in group. Staff my conduct random screens during group. If you are unable/unwilling to provide a urine sample your records will reflect a positive test as a result. Calling Out: Please call extension 1707 to call out: FIT Transportation: call by 9pm the day prior Child Care Services: call by 7:30am the day of IOP programming: call by 7:30am the day of *You must call out prior to the times indicated above or it will be considered a NO SHOW *If you no show child care or transportation a warning letter will be send sent. One more no show of child care or transportation after a warning letter has been received will lead to termination of either of these services. * Weather cancellations: Family willows closes according to Manchester School District snow emergencies. If Manchester schools are cancelled or delayed due to a weather emergency, IOP will also be closed Emergency Procedures: It is extremely important to reach out for help in an emergency! What is an Emergency?: At any time you feel that you are experiencing symptoms of your trauma or addiction such as severe anxiety or depression, you feel you may hurt yourself or someone else, you feel you may use substances. 1. Contact your IOP primary therapist and treatment coordinator if it is during programming hours. 2. If not during program hours, call Families in Transition s Hotline number: Clinical Emergency Phone: *Manchester Emergency Shelter will be screening the initial call. Clinical staff will call you back in a timely fashion 3. If you cannot reach anyone, go to your nearest hospital emergency room, or call
Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC
Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC Patient Name (please print): Welcome to the therapy services
More informationDale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648
Dale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648 Problems in love and work, as well as troubling symptoms like depression and anxiety, often lead people to seek therapy.
More informationNew Perspective Counseling Services Child/Teen Intake Form
Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.
More informationGarland s Christian Counseling Center
Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave
More informationNotice of Privacy Practices Of Melissa Gressner, PsyD
!"#$%&'())* +"&)),&" Change Is Possible Notice of Privacy Practices Of Melissa Gressner, PsyD THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
More informationADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code
ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from
More informationJEWISH FAMILY SERVICE NOTICE OF PRIVACY PRACTICES
Jewish Family Service takes pride in treating our clients and each other with respect and dignity. Protecting your health information is very important to us. We want you to have a clear understanding
More informationWe are so happy you booked your first appointment. Enclosed you will find your new client paperwork and some important information about our office.
Welcome to our practice! We are so happy you booked your first appointment. Enclosed you will find your new client paperwork and some important information about our office. You have two main things to
More informationAGAPE. Therapist Client Services Agreement
Revised 7/1/08 AGAPE Therapist Client Services Agreement AGAPE is a faith-based organization guided by Christian values. As part of its overall mission, AGAPE offers professional counseling and psychological
More informationCOLORADO PSYCHOTHERAPY DISCLOSURE STATEMENT AND PSYCHOLOGICAL SERVICES AGREEMENT
Jill Squyres, Ph.D. PO Box 2125 Eagle, CO 81631 drjsquyres@mac.com 970.306.69.86 (ph) 866.512.0078 (fax) COLORADO PSYCHOTHERAPY DISCLOSURE STATEMENT AND PSYCHOLOGICAL SERVICES AGREEMENT This services agreement
More informationBetsy Mencher, Ph.D. Licensed Clinical Psychologist 1350 Connecticut Avenue, NW Suite 602 Washington, DC 20036
Betsy Mencher, Ph.D. Licensed Clinical Psychologist 1350 Connecticut Avenue, NW Suite 602 Washington, DC 20036 PSYCHOLOGIST-CLIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement)
More informationOffice Hours and Availability
Clinton B. Clark, MA, LPC Counselor/Group Leader PO Box 365; Conifer, CO 80433 Phone: 303-591-7675 / email: clint@clintclarkma.com www.clintclarkma.com Important Information and Policies as You Begin Counseling
More informationIntake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:
Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name
More informationPSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER SERVICES
Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Sandra Mote, MS, CS, ARNP Patient Name (please print): Welcome to the psychotherapy and psychiatric
More informationConnecticut Carpenters Health Fund Privacy Notice
Connecticut Carpenters Health Fund Privacy Notice THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
More informationMetropolitan Living, LLC 151 W. Burnsville Parkway, Suite 101 Burnsville, MN 55337 Ph: (952) 564-3030 Fax: (651) 925-0031
The Health Insurance Portability and Accountability Act (HIPAA) and Client Privacy Statement This notice describes how your medical information may be used and disclosed and how you can get access to this
More informationPATIENT INTAKE FORM PATIENT INFORMATION. Name Soc. Sec. # Last Name First Name Initial Address. City State Zip. Home Phone Work/Mobile Phone
PATIENT INTAKE FORM PATIENT INFORMATION Name Soc. Sec. # Last Name First Name Initial Address City State Zip Home Phone Work/Mobile Phone Sex M F Age Birth date Single Married Widowed Separated Divorced
More informationPSYCHOTHERAPY CONTRACT
Aaron J. Dodini, Ph.D. Licensed Clinical Psychologist Licensed Marriage & Family Therapist PSYCHOTHERAPY CONTRACT Welcome to my practice. This document contains important information about my professional
More informationThe Family Counseling Center of Fulton County NOTICE OF PRIVACY PRACTICES
The Family Counseling Center of Fulton County NOTICE OF PRIVACY PRACTICES This notice describes the privacy practices of The Family Counseling Center of Fulton County and the privacy rights of the people
More informationSDC-League Health Fund
SDC-League Health Fund 1501 Broadway, 17 th Floor New York, NY 10036 Tel: 212-869-8129 Fax: 212-302-6195 E-mail: health@sdcweb.org NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION
More informationPSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary
More informationWELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work together and providing you with assistance.
Lorie Jenddryka, MS, LCPC, CH 800 E. Northwest Highway, Suite 500 Palatine, IL 60074 (847) 794-8836 WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work
More informationSouthern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889
Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document
More informationAnn Dunnewold, Ph.D., 2012
1 Ann Dunnewold, Ph.D. 8140 Walnut Hill Lane, Suite 100 Dallas, TX 75231 (214) 343-1353 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important
More informationIntegrative Psycho-Therapy and Assessment Services, P.L.L.C. PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT
Integrative Psycho-Therapy and Assessment Services, P.L.L.C. PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional
More informationFamily Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT
Family Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT Thank you for choosing Family Life Resource Center (FLRC) as your mental health provider. This document contains important
More informationPATIENT INFORMATION. Patients Last Name First MI. SSN: DOB Age Sex: M F. Address. City State Zip Code. Home Phone # Alt. Phone #
Boguslaw Gluszak, MD Date: PATIENT INFORMATION Patients Last Name First MI SSN: DOB Age Sex: M F Address City State Zip Code Home Phone # Alt. Phone # Parents/Guardians: N/A Name of Primary Insurance:
More informationDeborah Issokson, Psy.D.
Deborah Issokson, Psy.D. Licensed Psychologist HEALTHCARE PRIVACY AND SECURITY POLICIES PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important
More informationMendel Psychological Associates
PSYCHOLOGIST- PATIENT SERVICES AGREEMENT This document is an agreement between therapist: and client:. Welcome to our practice. This document (the Agreement) contains important information about professional
More informationIRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515
: / / Client Name: _ SSN: / / of Birth: Age: Sex: Male Female Address: City/State/Zip: Home Phone Number Is it okay to leave a message here? Y/N Work Number Is it okay to leave a message here? Y/N Cell
More informationTIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452
TIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452 Dorothy B. Brown, Ph.D. Anne Davidge, Ph.D. Dennis J. Rog, Ed.D. Licensed
More informationKiran Mishra, Ph.D. Licensed Clinical Psychologist. Sugar Land, TX 77478 (832) 876-3232 TEXAS NOTICE FORM
Kiran Mishra, Ph.D. Licensed Clinical Psychologist 1111 Highway 6, Suite 235 Sugar Land, TX 77478 (832) 876-3232 TEXAS NOTICE FORM Notice of Psychologists Policies and Practices to Protect the Privacy
More informationLEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL 60062
PHONE: 847.497.8378 LEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL 60062 Intake Form Date of Intake: Caller: DRLEIGHWEISZ.COM Referral Source: May I thank referral
More informationLIFESTREAM BEHAVIORAL CENTER, INC. JOINT NOTICE OF PRIVACY PRACTICES. Effective Date: April 14, 2003
LIFESTREAM BEHAVIORAL CENTER, INC. JOINT NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003 THIS DOCUMENT DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
More informationAnxiety Treatment Center, LLC
Anxiety Treatment Center, LLC 6 Forest Park Drive, 2 nd Floor 860 269 7813 Patient Information Sheet Name: Address: Phone (h) : Phone (w) : Phone (c) : Email: DOB: Family Members (Name, Age, Gender, Relationship)
More information650 Clark Way Palo Alto, CA 94304 650.326.5530
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. (Adopted 4-14-03; revised December 2006) If
More informationPSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT
The Bethesda Group Psychological Services, LLC Old Georgetown Office Park 7988 Old Georgetown Road, 8A Bethesda, Maryland 20814 Phone 301.718.4544 Fax 301.718.4545 info@thebethesdagroup.com PSYCHOTHERAPIST-PATIENT
More informationBradley D. Powell, PhD NOTICE OF PRIVACY PRACTICES: Effective June 1, 2004
Bradley D. Powell, PhD NOTICE OF PRIVACY PRACTICES: Effective June 1, 2004 A Summary of the Provisions of the Health Insurance Portability and Accountability Act ( HIPAA ) Privacy Rule (45 C.F.R. parts
More informationCOURTNEE A. PELTON, PSY.D.
1 COURTNEE A. PELTON, PSY.D. 703-343-0849 CPELTON.PSYCH@GMAIL.COM Outpatient Services Contract Welcome to my practice. This agreement contains important information about my professional services and office
More informationVALPARAISO UNIVERSITY NOTICE OF PRIVACY PRACTICES. Health, Dental and Vision Benefits Health Care Reimbursement Account
VALPARAISO UNIVERSITY NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
More informationPRIVACY POLICY (IN ACCORDANCE WITH HIPAA)
PRIVACY POLICY (IN ACCORDANCE WITH HIPAA) The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. This
More informationCounseling Intake Form (Each person attending therapy should complete a form)
Counseling Intake Form (Each person attending therapy should complete a form) Name Male Female Mailing Address Date of Birth Home Phone Work Email How would you like to be contacted? Home Work Email Okay
More informationDebbie Beach, LCSW Debbiebeach4@gmail.com 202-415-6242
Debbie Beach, LCSW Debbiebeach4@gmail.com 202-415-6242 COLLABORATIVE ENGAGEMENT AGREEMENT DIVORCE COACH Debbie Beach, LCSW 405 N. Washington St, #104 Falls Church, VA 22046 Date: Name of party: Dear Party:
More informationRiegler Shienvold & Associates (717) 540-1313 2151 Linglestown Road, Suite 200 Harrisburg, PA 17110
Riegler Shienvold & Associates (717) 540-1313 2151 Linglestown Road, Suite 200 Harrisburg, PA 17110 PROVIDER-PATIENT SERVICES AGREEMENT Welcome to Riegler Shienvold & Associates (RSA). This document (the
More informationLeonard M. Bohanon, PhD Psychologist
2203 Timberloch Pl., Suite 100 PERSONAL DATA RECORD Client Name: Date of Birth Address: City/State/Zip: Home Phone: Cell Phone: SSN: Work Phone: Other Phone: TXDL: Employer/School: Referred to Our Office
More informationJason S Berman, PhD, PLLC; Licensed Psychologist; 12830 Hillcrest, Suite 111 Dallas, Texas 75230; (214) 929-9244 PROFESSIONAL SERVICES CONTRACT
PROFESSIONAL SERVICES CONTRACT 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
More information9525 Katy Freeway, Suite 312 Houston, Texas 77024 Phone (713) 463-9449 Fax (713) 463-7181 www.bhchouston.com. Welcome Friend!
9525 Katy Freeway, Suite 312 Houston, Texas 77024 Phone (713) 463-9449 Fax (713) 463-7181 www.bhchouston.com Welcome Friend! Thank you for your interest in pursuing counseling services in this office.
More informationMAIL: Recovery Center Missoula FAX: 406 532 9901 1201 Wyoming St. OR ATTN: Admissions Missoula, MT 59801 ATTN: Admissions
Hello and thank you for your interest in Recovery Center Missoula. This letter serves to introduce our program to you, outline eligibility requirements, and describe the application/admission process.
More informationLattimore Physical Therapy and Sports Rehabilitation Network Monroe and Livingston County Clinics NOTICE OF PRIVACY PRACTICES
Lattimore Physical Therapy and Sports Rehabilitation Network Monroe and Livingston County Clinics NOTICE OF PRIVACY PRACTICES This notice describes the privacy practices of LATTIMORE PHYSICAL THERAPY AND
More informationNOTICE OF PRIVACY PRACTICES
Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR PLEDGE
More informationJerry M. Ruhl Ph.D. Clinical Psychologist (Texas #34359) 5200 Montrose Blvd. Houston, TX 77006
Jerry M. Ruhl Ph.D. Clinical Psychologist (Texas #34359) 5200 Montrose Blvd. Houston, TX 77006 CELL (937) 684-7746 PLEASE USE THIS NUMBER TO SCHEDULE OR CHANGE APPOINTMENTS INFORMED CONSENT FOR TREATMENT
More informationJames H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc.
James H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc. 89 Moraga Way, Suite B Tel: 925-285-2429 Orinda, CA 94563 Fax: 925-429-9259 Name
More informationSarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995
Sarasota Personal Medicine 1250 S. Tamiami Trail, Suite 202 Sarasota, FL 34239 Phone 941.954.9990 Fax 941.954.9995 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
More informationCOLLABORATIVE ENGAGEMENT AGREEMENT NEUTRAL DIVORCE COACH
COLLABORATIVE ENGAGEMENT AGREEMENT NEUTRAL DIVORCE COACH KAREN P. FREED, LCSW-C, LICSW, BCD 12007 Whippoorwill Lane North Bethesda, MD 20852 Ph: 301-816-0978 Email: kpfreed@hotmail.com This document constitutes
More informationDavid Shanley PsyD, LLC 1776 S. Jackson St., Suite 204 Denver, CO 80210 Psychologist Candidate #00013457
David Shanley PsyD, LLC 1776 S. Jackson St., Suite 204 Denver, CO 80210 Psychologist Candidate #00013457 DISCLOSURE INFORMATION & CONTRACT FOR PSCYHOLOGICAL SERVICES DATE: CLIENT NAME: BIRTHDATE: ADDRESS:
More informationChief Privacy Officer Christian Brothers Services 1205 Windham Parkway Romeoville, IL 60446-1679 cpo@cbservices.org 800-807-0100
Summary of Notice of Privacy Practices for Christian Brothers Prescription Drug Program Christian Brothers Services is the program sponsor of the Christian Brothers Prescription Drug Program (the Program
More informationHIPAA Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully. This practice is required by law to
More informationPATIENT / PSYCHOTHERAPIST SERVICE AGREEMENT INFORMED CONSENT. Welcome!
Jeremy Frank, PhD CADC Licensed Psychologist and Certified Alcohol and Drug Counselor Presidential City Madison Building 2 Bala Plaza, Suite Plaza 13 (Pl-13) Bala Cynwyd, Pennsylvania 19004 215-356-8061
More informationNOTICE OF PATIENT RIGHTS AND PRIVACY PRACTICES
1303 NE Cushing Dr. Suite 200 Bend, Oregon 97701 Phone (541) 318-0858 Fax (541) 318-6740 NOTICE OF PATIENT RIGHTS AND PRIVACY PRACTICES THIS INFORMATION IS PROVIDED TO YOU BY BEND SURGERY CENTER THIS NOTICE
More informationJ. Gary Dolinsky, Ph.D. 161 South Main Street, Suite 309 Licensed Psychologist Provider Middleton, MA 01949 (978) 750 1990 phone (978) 739 4042 fax
J. Gary Dolinsky, Ph.D. 161 South Main Street, Suite 309 Licensed Psychologist Provider Middleton, MA 01949 (978) 750 1990 phone (978) 739 4042 fax jgdol@aol.com www.jgarydolinskyphd.com Psychologist-Patient
More informationoimae ;vnv ;asv ;lskaj; afesldk PSYCHOTHERAPY SERVICES AGREEMENT
oimae ;vnv ;asv ;lskaj; afesldk 33493 West 14 Mile Road, Suite 130 Farmington Hills, MI 48331 (248) 851-KIDS (5437) ChildAndFamilySolutionsCenter.com afeaf eafeafew; PSYCHOTHERAPY SERVICES AGREEMENT This
More informationMarian R. Zimmerman, Ph.D.
Marian R. Zimmerman, Ph.D. Clinical Health Psychology www.mzpsychology.com 3550 Parkwood Blvd., 306 (214)618-1451 Phone Frisco, TX 75034 (214)618-2102 Fax Pre-Surgical Evaluation Patient Name: Age: Date
More informationJennifer L. Trotter, Ph.D.
Jennifer L. Trotter, Ph.D. Telephone: 248-880-4966 - Email: JenniferLTrotter@gmail.com Licensed Clinical Psychologist Address: 25882 Orchard Lake Road - Suite L-4 - Farmington Hills, MI 48336 OUTPATIENT
More informationJACQUELINE HOOD, PH.D. Licensed Psychologist Licensed Specialist in School Psychologist 972-827-7921 www.dallaschildpsychologist.com.
JACQUELINE HOOD, PH.D. Licensed Psychologist Licensed Specialist in School Psychologist 972-827-7921 www.dallaschildpsychologist.com Consent Form Welcome to my practice. This document contains important
More informationKeweenaw Holistic Family Medicine Patient Registration Form
Keweenaw Holistic Family Medicine Patient Registration Form How did you first learn of our Clinic? Circle one: Attended Lecture Internet KHFM website Newspaper Sign in window Yellow Pages Physician Friend
More informationIndiana Healthcare Physician Services Privacy Standards Notice of Health Information Practices
Indiana Healthcare Physician Services Privacy Standards Notice of Health Information Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW TO GET ACCESS TO
More informationSchindler Elevator Corporation
-4539 Telephone: (973) 397-6500 Mail Address: P.O. Box 1935 Morristown, NJ 07962-1935 NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
More informationRACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043. PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12)
RACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043 1 PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12) Welcome to my practice. This agreement contains important information
More informationBeth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606
Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606 CONSENT FOR EVALUATION AND TREATMENT Welcome to my practice. This document
More informationNOTICE OF PRIVACY POLICY. Effective:, 2013
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY. NOTICE OF PRIVACY POLICY Effective:, 2013 The
More informationWELCOME TO STRAITH HOSPITAL FOR SPECIAL SURGERY OUR PHILOSOPHY JOINT NOTICE OF PRIVACY PRACTICES
WELCOME TO STRAITH HOSPITAL FOR SPECIAL SURGERY During your stay with us, our goal is to make your hospital experience as favorable as possible by providing information and open channels of communication.
More informationlsh!urology ASSOCIATES OF HOUSTON, P.A.
, Gary lsh!urology ASSOCIATES OF HOUSTON, P.A. S. Hurwitz, M.D., F.A.C.S. Douglas S. Dow, M.D., F.A.C.S. Nathaniel L. Barnes, M.D., F.A.C.S. Thanh A. Nguyen, M.D., F.A.C.S. Matthew D. Hoggatt, M.D. Notice
More informationNOTICE OF HEALTH INFORMATION PRIVACY PRACTICES (HIPAA)
NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES (HIPAA) THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
More informationNotice of Privacy Practices
Notice of Privacy Practices Effective September 20, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
More informationOFFICE POLICIES AND SERVICE AGREEMENT
Thomas Cicciarelli, Psy.D. PSY17298 350 Parnassus Avenue, Suite 601. San Francisco, CA 94117. 415-767-5199 OFFICE POLICIES AND SERVICE AGREEMENT Introduction Welcome to my practice. This document contains
More informationNorthwest Cardiology Associates 400 W. Northwest Hwy Barrington, IL 60010 847.382.4600 Fax 847.382.1771. HIPAA Notice of Privacy Practices ( Notice )
Northwest Cardiology Associates 400 W. Northwest Hwy Barrington, IL 60010 847.382.4600 Fax 847.382.1771 HIPAA Notice of Privacy Practices ( Notice ) THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY
More informationDISCLOSURE AND CONSENT FORM
SCA INTAKE DOCUMENTS Thank you for your interest in Southwest Counseling Associates. This package contains all the documents you would typically receive when you arrive for your first session with an SCA
More informationThe Health and Benefit Trust Fund of the International Union of Operating Engineers Local Union No. 94-94A-94B, AFL-CIO. Notice of Privacy Practices
The Health and Benefit Trust Fund of the International Union of Operating Section 1: Purpose of This Notice Notice of Privacy Practices Effective as of September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL
More informationAnna M. Trad, Ph.D., 1244 Clairmont Road, Suite 204 Decatur, GA 30030
Anna M. Trad, Ph.D., 1244 Clairmont Road, Suite 204 Decatur, GA 30030 PSYCHOLOGIST - PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about
More informationTransitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047
Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Insurance Information Sheet It is important that you thoroughly complete
More informationHIPAA Privacy Notice
HIPAA Privacy Notice This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This notice describes
More information9129 Monroe Rd. Suite 100, Charlotte, NC 28270
9129 Monroe Rd. Suite 100, Charlotte, NC 28270 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.
More informationNotice of Privacy Practices. Introduction
Notice of Privacy Practices Introduction At Ohio Valley Medical Center and East Ohio Regional Hospital, we are committed to using and disclosing protected health information about you responsibly. This
More informationNichol A. Moses, Psy.D., NCSP
PATIENT INFORMATION SHEET It is our hope to provide the highest quality of service. Below you will find a patient information sheet which provides our office with useful information that is helpful to
More informationNotice of Privacy Practices
Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Privacy is a very
More informationMichael S. McLane, Psy.D. Licensed Psychologist. Informed Consent to Treatment / Evaluation I,, who was born on and who resides at
Michael S. McLane, Psy.D. Licensed Psychologist 12830 Hillcrest Road Suite D233 Dallas, TX 75230 Ph: (972) 620-1225 Fax: (972) 620-4393 Informed Consent to Treatment / Evaluation I,, who was born on and
More informationCounseling Associates of Southern Illinois 1669 Windham Way, Suite B O Fallon, Illinois 62269 P: 618-622-2579 F: 618-624-8506 www.casicounseling.
Counseling Associates of Southern Illinois 1669 Windham Way, Suite B O Fallon, Illinois 62269 P: 618-622-2579 F: 618-624-8506 www.casicounseling.org I. Initial Client Information Date: Social Security
More informationKathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677
Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677 Welcome! Please take a minute to complete the following information. Your name: Phone Number: Address:
More informationBrian Nussbaum, Psy.D. 06/09 1
Tampa Psychology Brian Nussbaum, Psy.D. Licensed Clinical Psychologist, FL license# PY6830 27446 Cashford Circle #101 Wesley Chapel, FL 33544 (813) 545-7754 Welcome to my practice. This document contains
More informationJANET PURCELL, PH.D. 1818 N.E. IRVING STREET PORTLAND, OR 97232 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT
JANET PURCELL, PH.D. 1818 N.E. IRVING STREET PORTLAND, OR 97232 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT This document contains important information about my professional and business policies. It also
More informationPrivacy Notice. The Plan s duties with respect to health information about you
Privacy Notice Please carefully review this notice. It describes how medical information about you may be used and disclosed and how you can get access to this information. The Health Insurance Portability
More informationHIPAA NOTICE OF PRIVACY PRACTICES
HIPAA NOTICE OF PRIVACY PRACTICES Marden Rehabilitation Associates, Inc. Marden Rehabilitation Associates of Ohio, Inc. Marden Rehabilitation Associates of West Virginia Health Care Plus Preferred Care
More informationDelaware Valley Dermatology Group, LLC 3411 Silverside Road Suite 107, Webster Building Wilmington, DE 19810 Phone: 302-478-8532 Fax: 302-478-8536
Delaware Valley Dermatology Group, LLC 3411 Silverside Road Suite 107, Webster Building Wilmington, DE 19810 Phone: 302-478-8532 Fax: 302-478-8536 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW
More informationPsychological Services & Holistic Health, Inc.
Psychological Services & Holistic Health, Inc. 626 Wilshire Boulevard, Suite 910 3990 Westerly Place, Suite 160 Los Angeles, CA 90017 Newport Beach, CA 92660 Phone: (213) 622-0633 Fax: (213) 622-5633 NOTICE
More informationNotice of Privacy Practices
SHANNON LERACH, Ph.D. Licensed Clinical Psychologist PSY23705 243 N. Highway 101, Suite 16, Solana Beach, CA 92075 Telephone: (619) 817.5320 Fax: (858) 481.1674 Notice of Privacy Practices This Notice
More informationNeera Agarwal-Antal, M.D. HIPAA Policies and Procedures
Neera Agarwal-Antal, M.D. HIPAA Policies and Procedures HIPAA POLICIES & PROCEDURES This packet includes the following HIPAA policies, procedures and model forms: HIPAA General Operating Policy...1 Authorization
More informationGOALS OF COUNSELING RISKS/BENEFITS OF COUNSELING
1 Welcome to. This document contains important information about my professional services and business policies. Attached is also a summary of information about the Health Insurance Portability and Accountability
More informationNotice of Privacy Practices
Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. About this notice
More informationHIPAA NOTICE OF PRIVACY PRACTICES Woodlands Behavioral Healthcare Network (WBHN)
HIPAA NOTICE OF PRIVACY PRACTICES Woodlands Behavioral Healthcare Network (WBHN) Effective Date: 04/14/15 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN
More informationHIPAA PRIVACY NOTICE PLEASE REVIEW IT CAREFULLY
HIPAA PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. INTRODUCTION PLEASE REVIEW IT CAREFULLY Moriarty
More information