Jayme Yodice, MA 1905 J.N. Pease Place Suite 104 Licensed Psychological Associate Charlotte, NC NC

Size: px
Start display at page:

Download "Jayme Yodice, MA 1905 J.N. Pease Place Suite 104 Licensed Psychological Associate Charlotte, NC NC"

Transcription

1 Jayme Yodice, MA 1905 J.N. Pease Place Suite 104 Licensed Psychological Associate Charlotte, NC NC Psychological Testing Fees and Consent for Services Welcome! Psychological testing can provide valuable information to help you make decisions regarding educational needs, to clarify a more accurate diagnosis/ diagnoses or to help provide recommendations for treatment. Psychological testing services are different from therapy services. Usually, there is an intake session where information is gathered about what the testing needs are and background information is obtained if needed. Testing sessions vary from 1-5 sessions depending on the needs. Sessions can range from 1 hour to up to 3 hours. I make every effort to keep testing session lengths reasonable so that clients are not fatigued which could impact their performance. Thus, this can result in an increased number of sessions. Fees: Because I value our relationship with you and believe that the best relationships are based on understanding, I offer these clarifications on payment and cancellations. Please see separate statement about BCBS and insurance for psychological testing. $120 for initial appointment (intake session) $120 per hour for testing (for every face to face hour, there is an additional hour of billing for test scoring, report writing, editing of reports, as well as cost of tests and test materials) $100 for a one-hour parent feedback of psychological test results -IQ test only (WISC-V or WPPSI-IV): $300 per testing including write-up. This usually occurs in 1, 2-3 hour session -Achievement Test only (Woodcock Johnson Test of Achievement IV): $300 per testing including write-up. This usually occurs in 1, 2-3 hour session -Psycho-educational battery and full report with recommendations: This battery includes an IQ test, achievement test, diagnostic interviewing, a full report with recommendations and a feedback session. $900 -Pre-K testing (to determine if child meets criteria for possible early admission to Kindergarten). This includes IQ and Achievement testing. The Full cost is $ This does not include a feedback session. -ADHD Testing: This battery can include a variety of testing measures depending on current needs. If no recent IQ or Achievement measures have been given, they will be included in this evaluation. Sometimes extended achievement testing is not needed to do an ADHD evaluation and unnecessary testing will not be given in order to keep costs down for clients. This evaluation can include but is not limited to: -IQ -Achievement -Conners-3 and other self-report measures

2 -Self report measures to identify any co-occurring issues such as anxiety or depression -Additional tests to measure processing speed, visual-motor skills -observation of client s behavior in the office OR at school if needed (additional fees may be included) -Full report with all results and recommendations -Feedback session to review ALL results, recommendations, and if agreed with written consent, information can be faxed to client s school. -Cost: A typical comprehensive evaluation for ADHD will range between $1200 and $1400 depending on which measures are needed. Additional costs may be accrued if you request that I do school observations or review multiple previous evaluations or records. These fees will be discussed up-front and agreed upon in writing. -Psychological Evaluations (which may include any of the above) this evaluation is used when mental health/ diagnoses are the primary questions. This type of evaluation may also include IQ, Achievement, Measures to assess for ADHD mentioned above, personality tests such as the PAI or MMPI, other self-report measures, in depth diagnostic interviewing with client and/ or multiple sources with client consent, review of records, consultation with medical providers if client has co-occurring medical issues. Cost: $1500 (cost can be minimized if some testing measures are not needed). Additional costs may be accrued if you request that I do school observations or review multiple previous evaluations or records. These fees will be discussed up-front and agreed upon in writing. Evaluation for Lap-band/ Gastric Bypass Surgeries: Making the decision to undergo extensive surgery for weight loss is an important one. Surgeons require a psychological evaluation to ensure the patient is emotionally ready for surgery, understands the behavioral/ lifestyle changes that must be made now and after surgery and also to offer supportive counseling to those who may need it. Jayme Yodice, LPA is not a medical doctor and therefore does not give medical advice. An evaluation for this purpose by Jayme Yodice consists of a clinical interview to ask about current health and eating behaviors, the administration of several self-report measures to further assess for depression, anxiety or other concerns, feedback with recommendations on how the patient can best cope with surgery and the expectations afterward. Jayme Yodice can also be available to provide therapy if needed for patients who need that extra support and motivation. Evaluation costs vary but typically range from $ Some insurance may cover a portion of the evaluation, and some may not. A fee of $100 is collected upfront, insurance is then billed and any amount not covered is due before results are given to the patient. Gestational Carrier Candidates Psychological Evaluation: A psychological evaluation for a gestational carrier candidate involves a clinical interview and completion of the Personality Assessment Inventory (PAI) for the carrier candidate and their partner if applicable. Clinical interviews may also be required for the intended parents and some fertility clinics also require that all parties involved (both couples) have a full psychological (clinical interview and personality inventory). This may include partners and spouses. The cost of the evaluation range from $260 for the gestational carrier candidate alone, to $800 for evaluations for the entire group (assuming there are 4 in the group). The fee includes time spent face-to-face in the office and time for the psychologist to score, interpret the PAI and assimilate all the information into a report. Insurance does not cover this service. Payment is due at the first appointment. Most sessions are minutes per individual including time to complete the PAI. Followup reports are usually completed with 2-3 weeks of the last appointment completed for the entire group. All parties involved must sign Consent For Release forms allowing all involved access to the information in the report, as well as any agency requesting the information. Special note about fees for psychological testing: Insurances vary with whether or not they cover psychological testing and often require pre-authorization and do not cover the hours needed. If I am in network for your insurance (BCBS only), I will file for the initial session, testing sessions and follow-up sessions. Applicable co-pays are due at each session. If out of network, half the FULL testing fee is due at

3 the first testing session with subsequent payments broken down in future sessions and full payment is due prior to receiving testing results (including reports, feedback sessions, or requesting me to send results to a third party). If I am out of network, full rates are due and broken up over sessions as outlined above or as agreed upon noted on the signature page of this form. This also applies to clients for whom I am in network but the client has deductibles. I will provide receipts for testing services if clients wish to seek reimbursement on their own. My fee remains the same regardless of whether or not insurance reimburses you. If you have BCBS and for some reason they deny testing services or it is not covered under your plan, you will owe FULL psychological testing fees. PLEASE SEE NOTICE ABOUT BCBS Release of Information: In addition, testing results cannot be released without your specific written consent (see my privacy policies for more information). By signing below, I acknowledge primary responsibility for the payment of services to Jayme Yodice, LPA. I request that if I have been informed that my insurance will cover testing, Jayme Yodice, LPA will seek reimbursement and is permitted to release psychological information to the insurance carrier, or case manager, when the information is requested to process claims. I do not object to this information being released by mail, fax or phone. If Jayme Yodice is out of network or testing is not covered, Jayme Yodice will provide you with a receipt of services received and fees paid so that you can seek reimbursement on your own. Confidentiality and Privacy Notices The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain requirements imposed by HIPPA. See our Notice of Privacy Practices for more information. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities as follows: I am required by the NC Psychology Board to meet regularly with a Licensed Psychologist for consultation and supervision. This is to ensure I am providing the best care to clients and to seek consultation when needed. During these meetings, I make every effort to avoid revealing the identity of my clients and the psychologist I meet with is also legally bound to keep the information confidential. I will note all consultations in your clinical record (which is called PHI in my Notices of Privacy Practices). Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this agreement. If I believe that a client presents an imminent danger to his/her health or safety, I may be obligated to seek hospitalized for her/her or to contact family members or others who can help provide protection. By state law, there are certain exceptions to confidentiality that you should be aware of: 1) If you threaten to harm or kill yourself or another person, I am legally and ethically required to take action to protect the safety of the threatened person. Possible actions could include informed the intended victim, arranging for your hospitalization, notifying family or support system or alerting law enforcement. 2) If I know or suspect abuse or neglect of a child, an elder person or a disabled person, I am required to report my concerns to County Department of Social Services. 3) If you are involved in a court proceeding and a request is made for information concerning the professional services that I have provided you, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your written authorization, or a court order. If you

4 are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. 4) If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. 5) If a patient files a worker s compensation claim, and my services are being compensated through worker s compensation benefits, I must, upon appropriate request, provide a copy of the patient s record to the patient s employer or the North Carolina Industrial Commission. 6) If you name me in a lawsuit, the law states that I can, and sometimes am obligated to reveal information that would otherwise be confidential or order to defend myself. If such situations arise, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in your Clinical Record. You may examine or receive a copy of your record if you request it in writing. Because these are professional records, they can be misinterpreted and/ or upsetting to untrained readers; therefore, I recommend you initially review them in my presence or have them forwarded to another mental health professional so you can discuss the contents. I am allowed to charge a copying fee per page. If I refuse your request for access to your records, you have a right to a review, which I will discuss with you upon request. Patient Rights You have now been given a copy of the Notice of Privacy Practices and been given an opportunity to discuss any questions that you have. This notice is also displayed in my office lobby area if you should ever want to review it. By signing at the end of this Consent for Treatment, you are confirming that you have received a copy. Cancellations I require 48-hours-notice if you need to cancel/ re-schedule a psychological testing appointment. When psychological testing session are scheduled, 2-4 hours of my time are set aside specifically for you. Therefore if you do not give me 48-hours-notice for re-scheduling, I charge a fee of $40 per hour (if 2 hours were blocked for testing, this fee would be $80). Exceptions to this are when emergencies arise and you should contact me when you are able to re-schedule. If missed appointments or frequent re-scheduling occurs, this can result in termination of psychological testing services.

5 Signature Page and Consent for Psychological Testing Services After discussing the evaluations being offered, I have decided to choose at a rate of. I understand that half the FULL fee is due at the first session which may be today and we have agreed at the following additional payment arrangement: due at session 2 due at session 3 -Payment in full due by: Regarding refunds: We do not offer refunds if you are unhappy with the evaluation, report, clinical suggestions or recommendations; we do not offer refunds if your insurance company refuses reimbursement of our services; we do not offer refunds under any circumstances. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS DOCUMENT AND YOU HAVE BEEN PROVIDED A COPY OF OUR PRIVACY PRACTICES, AND AGREE TO ABIDE BY THESE TERMS DURING OUR PROFESSIONAL RELATIONSHIP. Please sign and date below to indicate that you have read the preceding information in full, and understand the information. Please ask for clarification of any information you are unclear about. I agree to the statements herein and the terms of payment. Client: / / (Signature) (Printed Name) (Date Signed) psychologist: / / (Signature) (Printed Name) (Date Signed)

Psychological Services Agreement

Psychological Services Agreement John A. Watterson, Ph.D. 4101 Parkstone Heights Drive, Suite 260 Austin, Texas 78746 Phone: 512-306-0663 Fax: 512-306-8086 Website: www.johnwatterson.com Psychological Services Agreement Welcome to my

More information

LICENSED CLINICAL SOCIAL WORKER-PATIENT SERVICES AGREEMENT

LICENSED CLINICAL SOCIAL WORKER-PATIENT SERVICES AGREEMENT LICENSED CLINICAL SOCIAL WORKER-PATIENT SERVICES AGREEMENT PLEASE KEEP THIS DOCUMENT FOR YOUR RECORDS Welcome to our practice. This document (the Agreement) contains important information about my professional

More information

Lou Eckart, Ph.D. and Associates Licensed Clinical Psychologists 22 Mill St. Suite 305 Arlington, MA

Lou Eckart, Ph.D. and Associates Licensed Clinical Psychologists 22 Mill St. Suite 305 Arlington, MA Lou Eckart, Ph.D. and Associates Licensed Clinical Psychologists 22 Mill St. Suite 305 Arlington, MA 02476 781-646-6306 Lou@Eckart-PhD.com PSYCHOLOGIST - PATIENT SERVICES AGREEMENT Welcome to our practice.

More information

Sandra V Heinsz, Ph.D. Informed Consent Services Agreement

Sandra V Heinsz, Ph.D. Informed Consent Services Agreement Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance

More information

POLICIES OF THE ASSESSMENT CENTER AT OAK HILL ACADEMY

POLICIES OF THE ASSESSMENT CENTER AT OAK HILL ACADEMY 9407 Midway Road Dallas, Texas 75220 Phone: 214-353-9323 Fax: 214-239-2958 POLICIES OF THE ASSESSMENT CENTER AT OAK HILL ACADEMY This document contains information about the Assessment Center at Oak Hill

More information

Informed Consent for Assessment

Informed Consent for Assessment Informed Consent for Assessment Thank you for making the decision to pursue an evaluation with me. This document contains important information about my professional services and business policies. Please

More information

PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT COLORADO

PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT COLORADO Heidi A. Sauder, Ph.D. Sauder Psychology, Inc. 9085 E. Mineral Cir., Suite 235 Centennial, CO 80112 720.548.7825 heidi@sauderpsychology.com www.sauderpsychology.com PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT

More information

John W. Steele, Ph.D., Licensed Psychologist 1285 Fairfield Drive, Boulder, CO 80305

John W. Steele, Ph.D., Licensed Psychologist 1285 Fairfield Drive, Boulder, CO 80305 John W. Steele, Ph.D., Licensed Psychologist 1285 Fairfield Drive, Boulder, CO 80305 PSYCHOLOGIST-CLIENT DISCLOSURE STATEMENT AND SERVICES AGREEMENT Welcome to my practice. This document (the Agreement)

More information

Roger A. Olsen, Psy.D., L.P Slater Road, Suite 210 Eagan, MN Phone: FAX:

Roger A. Olsen, Psy.D., L.P Slater Road, Suite 210 Eagan, MN Phone: FAX: Roger A. Olsen, Psy.D., L.P. 4660 Slater Road, Suite 210 Eagan, MN 55122 Phone: 651-882-6299 FAX: 651-683-0057 INFORMATION FOR NEW CLIENTS Welcome to my practice. This document contains important information

More information

Stacie Beam-Bruce, LICSW, ACHt License# LW Main Ave S Suite 203 North Bend, WA 98045

Stacie Beam-Bruce, LICSW, ACHt License# LW Main Ave S Suite 203 North Bend, WA 98045 Stacie Beam-Bruce, LICSW, ACHt License# LW601172112 103 Main Ave S Suite 203 North Bend, WA 98045 INFORMED CONSENT AND CLIENT AGREEMENT WELCOME TO MY PRACTICE. I am pleased to have the opportunity to work

More information

Karen LeVasseur, LCSW Calm4Kids Therapy Center, LLC 514 Main Street Bradley Beach, NJ

Karen LeVasseur, LCSW Calm4Kids Therapy Center, LLC 514 Main Street Bradley Beach, NJ Karen LeVasseur, LCSW Calm4Kids Therapy Center, LLC 514 Main Street Bradley Beach, NJ 07720 732 272 8624 THERAPIST CLIENT SERVICE AGREEMENT/INFORMED CONSENT Welcome to my practice. This document contains

More information

WELCOME. Payment will be expected at the time of service. Please remember our 24 hour cancellation notice.

WELCOME. Payment will be expected at the time of service. Please remember our 24 hour cancellation notice. WELCOME Those of us at Crossroads Counseling want to thank you for choosing to work with us and we want to make your time with us as productive as possible. In order to expedite the intake process, please

More information

Education, Training and Licensure

Education, Training and Licensure Meredith M. Sargent, Ph.D. Licensed Clinical Psychologist 2950 Northup Way, Suite 204 Bellevue, Washington 98004 425.739.4772 (phone) 425.739.4778 (fax) msargentphd@gmail.com Welcome to my practice! I

More information

Jodi Bremer-Landau, PhD Licensed Psychologist

Jodi Bremer-Landau, PhD Licensed Psychologist WELCOME TO MY PRACTICE Welcome! I recognize that it takes a lot of courage to seek services and I truly appreciate your interest in working together. I look forward to making progress with you as we journey

More information

Lily M. Gutmann, Ph.D., CYT Licensed Psychologist 4405 East West Highway #512 Bethesda, MD (301)

Lily M. Gutmann, Ph.D., CYT Licensed Psychologist 4405 East West Highway #512 Bethesda, MD (301) Lily M. Gutmann, Ph.D., CYT Licensed Psychologist 4405 East West Highway #512 Bethesda, MD 20814 (301) 996-0165 www.littlefallscounseling.com PRACTICE POLICIES AND CONSENT TO TREATMENT WELCOME Welcome

More information

OREGON HIPAA NOTICE FORM

OREGON HIPAA NOTICE FORM MARCIA JOHNSTON WOOD, Ph.D. Clinical Psychologist 5441 SW Macadam, #104, Portland, OR 97239 Phone (503) 248-4511/ Fax (503) 248-6385 - Effective Sept.23, 2013 - (This copy for you to keep) OREGON HIPAA

More information

OUTPATIENT SERVICES CONTRACT 2018

OUTPATIENT SERVICES CONTRACT 2018 1308 23 rd Street S Fargo, ND 58103 Phone: 701-297-7540 Fax: 701-297-6439 OUTPATIENT SERVICES CONTRACT 2018 Welcome to Benson Psychological Services, PC. This document contains important information about

More information

Basic Information. Date: Patient s Name: Address:

Basic Information. Date: Patient s Name: Address: 1 Basic Information : Patient s Name: Address: Home Phone: Work Phone: Cell Phone: Email: Age: Birth : Marital Status: Occupation: Educational History: Name, Address and Phone of Child s School Counselor

More information

New York Notice Form Notice of Psychologists Policies and Practices to Protect the Privacy of Your Health Information

New York Notice Form Notice of Psychologists Policies and Practices to Protect the Privacy of Your Health Information New York Notice Form Notice of Psychologists Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

More information

DISCLOSURE AND POLICY STATEMENT

DISCLOSURE AND POLICY STATEMENT ERIN A. BEASLEY, Ph.D. Licensed Child & Adolescent Psychologist (206) 661-3199 DISCLOSURE AND POLICY STATEMENT PLEASE READ AND SIGN Welcome to my practice. I am pleased to have the opportunity to work

More information

Welcome to Canton Counseling Career Counseling Intake Form

Welcome to Canton Counseling Career Counseling Intake Form Welcome to Canton Counseling Career Counseling Intake Form The purpose of the following questionnaire is to help your counselor understand some important things about you in order to help you most effectively.

More information

(PLEASE PRINT) Sex M F Age Birthdate Single Married Widowed Separated Divorced. Business Address Business Phone Cell Phone

(PLEASE PRINT) Sex M F Age Birthdate Single Married Widowed Separated Divorced. Business Address Business Phone Cell Phone (PLEASE PRINT) Emma Warner, MSW, LCSW, ACSW Tulsa, OK 74105 (918) 749-6935 Personal Information Name Address Last Name First Name Initial Home Phone Soc. Sec. # City State Zip Sex M F Age Birthdate Single

More information

THE COUNSELING PLACE ADULT INTAKE FORM Yearly Family Income:

THE COUNSELING PLACE ADULT INTAKE FORM Yearly Family Income: Person to Contact in Case of Emergency Name Relationship Best Contact Number Alternative Contact Number Office Use Only Intake Date Reason for referral Counselor THE COUNSELING PLACE ADULT INTAKE FORM

More information

MIND MATTERS PSYCHIATRYMD PATIENT INTAKE FORMS LONG PRAIRIE ROAD SUITE 100 FLOWER MOUND, TX 75022

MIND MATTERS PSYCHIATRYMD PATIENT INTAKE FORMS LONG PRAIRIE ROAD SUITE 100 FLOWER MOUND, TX 75022 MIND MATTERS PSYCHIATRYMD PATIENT INTAKE FORMS 2017 2620 LONG PRAIRIE ROAD SUITE 100 FLOWER MOUND, TX 75022 Whose # is this? Whose # is this? 2 2 3 4 fa 5 6 X 7 8 Mind Matters PsychiatryMD Patient Responsibilities

More information

Psychologist-Patient Services Agreement

Psychologist-Patient Services Agreement Psychologist-Patient Services Agreement Welcome! This document contains important information about my professional services and business policies. This document also contains a brief summary of information

More information

Client Information Form

Client Information Form Client Information Form Please read and complete all information requested. Date: Name: Address: City, State and Zip: Social Security Number: Home Phone: Work Phone: Cell Phone: E-mail: If client is a

More information

Nathan Swisher, PsyD, PLLC

Nathan Swisher, PsyD, PLLC Nathan Swisher, PsyD, PLLC www.swishercounseling.com 970.381.6093 Client Intake Packet 1. Disclosure and Consent to Treatment (pages 2-4) - This form outlines my education, registration, your rights in

More information

Linda F. Little, Ph.D. Clinical Psychologist

Linda F. Little, Ph.D. Clinical Psychologist Page1 Phone: 360-385-7459 Linda F. Little, Ph.D. Clinical Psychologist Email: LindaFLittlePhD@gmail.com License: PY60468249 Welcome! You have made an important decision to deal with a challenge or change

More information

Comprehensive Counseling & Consulting, LLC

Comprehensive Counseling & Consulting, LLC Welcome to Comprehensive Counseling & Consulting, LLC! We look forward to working with you! Below you will find the intake packet which may be printed out and completed before your first appointment. We

More information

Disclosure Statement

Disclosure Statement Disclosure Statement The state of Colorado requires that I, as a licensed psychotherapist, provide the following items of information to you as a client: Business Address and Phone: Mooney and Associates,

More information

INFORMED CONSENT FOR TREATMENT

INFORMED CONSENT FOR TREATMENT INFORMED CONSENT FOR TREATMENT I (name of patient), agree and consent to participate in behavioral health care services offered and provided at/by Children s Respite Care Center, a behavioral health care

More information

NOTICE OF PRIVACY PRACTICES

NOTICE 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. Who Presents this

More information

1.2 ADULT CLIENT INTAKE FORM: Client Information

1.2 ADULT CLIENT INTAKE FORM: Client Information 1.2 ADULT CLIENT INTAKE FORM: Client Information FOR OFFICIAL USE ONLY: Client Number Effective Insurance No OH No CLIENT INFORMATION Client name of significant other CHILDREN INFORMATION of birth of birth

More information

LCSW, CGT, SRT 7710 N.

LCSW, CGT, SRT 7710 N. Date Completed:, CGT, SRT Name: Age: D.O.B. Name: Age: D.O.B. Address (Street) City, State, Zip Home: Cell: Email: Email: Work: Is it OK to leave messages at: Home? Y N Work? Y N Cell? Y N Is it OK to

More information

Emergency Contact: Name Relationship Address

Emergency Contact: Name Relationship Address Participant Information Name Treatment Start Date Address City State Zip Home/Cell Phone Work Phone Birth date Age SSN Marital Status Primary Insurance Provider Insurance ID # Primary Insured Name: Primary

More information

Barbara K. McEntee, Ph.D., PLLC 4815 S. Harvard Ave., Suite 470, Tulsa, Oklahoma 74135 Phone: 918-392-4866 Fax: 918-392-4867 www.barbaramcenteephd.com Thank you for the opportunity to provide psychological

More information

SUMMARY OF NOTICE OF PRIVACY PRACTICES

SUMMARY OF NOTICE OF PRIVACY PRACTICES LAKE REGIONAL MEDICAL GROUP 54 HOSPITAL DRIVE OSAGE BEACH, MO 65065 SUMMARY OF NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU

More information

HIPAA PRIVACY NOTICE

HIPAA PRIVACY NOTICE HIPAA PRIVACY NOTICE PLEASE REVIEW THIS NOTICE CAREFULLY. IT DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU MAY GAIN ACCESS TO THAT INFORMATION. POLICY STATEMENT This Practice

More information

always legally required to follow the privacy practices described in this Notice.

always legally required to follow the privacy practices described in this Notice. The ANXIETY & STRESS MANAGEMENT INSTITUTE 1640 Powers Ferry Rd, Building 9, Suite 10 0, Marietta, Georgia 30067, 770-953-0080 Health Insurance Portability and Accountability Act (HIPAA) NOTICE OF PRIVACY

More information

WAKE FOREST BAPTIST HEALTH NOTICE OF PRIVACY PRACTICES

WAKE FOREST BAPTIST HEALTH NOTICE OF PRIVACY PRACTICES WAKE FOREST BAPTIST HEALTH NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 Revised February 17, 2010 Revised September 23, 2013 Revised July 1, 2016 This Notice of Privacy Practices applies to the

More information

Counseling Disclosure Statement

Counseling Disclosure Statement Mary Peters, MA, LMHC, PS, Inc. State Of Washington Licensed Counselor, LC00046555 NPI 1568570612 EIN 80-0357363 631 5 th Street, Suite 201 Mukilteo, WA 98275 Counseling Disclosure Statement Thank you

More information

Slide 1 WHO IS THE CLIENT? WHO CONTROLS THE RECORD? ETHICS AND HIPAA. Slide 2. Slide 3. The Four As of Ethical Practice

Slide 1 WHO IS THE CLIENT? WHO CONTROLS THE RECORD? ETHICS AND HIPAA. Slide 2. Slide 3. The Four As of Ethical Practice Slide 1 WHO CONTROLS THE RECORD? ETHICS AND HIPAA 22 nd Oklahoma Child Abuse & Neglect Conference Norman, Oklahoma, on September 4, 2014 Dr. Arlene B. Schaefer, Ph.D. Forensic and Clinical Psychology Oklahoma

More information

PATIENT INTAKE PACKET

PATIENT INTAKE PACKET PATIENT INTAKE PACKET Welcome to the CannaMD family - you're in great hands! To reduce your visit and wait time, we ask that you please complete and submit this intake packet at least 24 hours prior to

More information

Texas Mental Health Law

Texas Mental Health Law Texas Mental Health Law J. Ray Hays, Ph.D. Directions: To receive 4 hours continuing education credit for psychologists, licensed psychological associates, licensed professional counselors and licensed

More information

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA IRVINE HEALTHSYSTEM

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA IRVINE HEALTHSYSTEM Effective Date: April 14, 2003 NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA IRVINE HEALTHSYSTEM THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

More information

Reminders for you as you come in for your first appointment

Reminders for you as you come in for your first appointment Reminders for you as you come in for your first appointment * Please complete this paperwork and bring it to your first appointment If you are unable to complete this paperwork prior to your appointment,

More information

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA RIVERSIDE CAMPUS HEALTH CENTER

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA RIVERSIDE CAMPUS HEALTH CENTER NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA RIVERSIDE CAMPUS HEALTH CENTER Effective Date: April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND

More information

PATIENT BILL OF RIGHTS & NOTICE OF PRIVACY PRACTICES

PATIENT BILL OF RIGHTS & NOTICE OF PRIVACY PRACTICES Helping People Perform Their Best PRIVACY, RIGHTS AND RESPONSIBILITIES NOTICE PATIENT BILL OF RIGHTS & NOTICE OF PRIVACY PRACTICES Request Additional Information or to Report a Problem If you have questions

More information

Intake Form for Child/Adolescent Psychotherapy. Child s name: DOB/Age: Address: Phone number: (C) (H)

Intake Form for Child/Adolescent Psychotherapy. Child s name: DOB/Age: Address: Phone number: (C) (H) Intake Form for Child/Adolescent Psychotherapy Child s name: DOB/Age: Address: Phone number: (C)(H) Child primarily lives with: Both parents Mother Father Other Legal Guardian Name: DOB: Address: Phone:

More information

Disclosure Statement & Policies

Disclosure Statement & Policies This contains important information. Please review it carefully. Everyone fifteen (15) years and older must sign this disclosure. A parent or legal guardian with the authority to consent to mental health

More information

AGREEMENT FOR SERVICE / INFORMED CONSENT FOR MINORS

AGREEMENT FOR SERVICE / INFORMED CONSENT FOR MINORS Introduction AGREEMENT FOR SERVICE / INFORMED CONSENT FOR MINORS This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by San Diego Psychotherapy

More information

HIPAA Notice of Privacy Practices

HIPAA Notice of Privacy Practices HIPAA Notice of Privacy Practices Georgia Mountains Hospice understands that your health information is highly personal and we are committed to safeguarding your privacy. Please read this Notice of Privacy

More information

PEDIATRIC HEALTH ASSOCIATES HIPAA NOTICE OF PRIVACY PRACTICES

PEDIATRIC HEALTH ASSOCIATES HIPAA NOTICE OF PRIVACY PRACTICES Policy effective date: 4-14-2003 Revised January 2014 PEDIATRIC HEALTH ASSOCIATES HIPAA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND

More information

Christina Unruh, MSW, LCSWA Initial Intake Packet

Christina Unruh, MSW, LCSWA Initial Intake Packet Christina Unruh, MSW, LCSWA Intake Packet 1 Christina Unruh, MSW, LCSWA Initial Intake Packet Date CLIENT NAME: FIRST MIDDLE LAST Nickname: Date of Birth / / Age Address City Zip Code Phones: Mobile Home

More information

INTAKE REGISTRATION FORM

INTAKE REGISTRATION FORM INTAKE REGISTRATION FORM Therapist: of Appt: File Created Practice Fusion: Discovering new choices together File Created Kareo: Today s : PCP: CLIENT INFORMATION Last Name First M.I. D.O.B Marital Status

More information

A Better You Counseling Services, LLC 1225 Johnson Ferry Road, Ste 170 Marietta GA

A Better You Counseling Services, LLC 1225 Johnson Ferry Road, Ste 170 Marietta GA A Better You Counseling Services, LLC 1225 Johnson Ferry Road, Ste 170 Marietta GA 30068 404-216-1135 Health Insurance Portability and Accountability Act (HIPAA) NOTICE OF PRIVACY PRACTICES I. COMMITMENT

More information

LYNDA HARRINGTON, LCSW Licensed Clinical Social Worker LCS 15732

LYNDA HARRINGTON, LCSW Licensed Clinical Social Worker LCS 15732 LYNDA HARRINGTON, LCSW Licensed Clinical Social Worker LCS 15732 2412 Professional Drive, Roseville, CA 95661 (916) 678-0706, FAX (916) 772-2442 lyndaharringtonlcsw@gmail.com website: lyndaharringtonlcsw.com

More information

RIVER CITY ADVOCACY COUNSELING SERVICES 145 Landa Street New Braunfels, TX (830)

RIVER CITY ADVOCACY COUNSELING SERVICES 145 Landa Street New Braunfels, TX (830) Date / / Client information: First name Middle initial Last name Parent/Legal Guardian (for 17 and under) Address Phone number Home Wk Cell Date of birth / / Sex Marital Status Ethnicity Employment status:

More information

NOTICE OF PRIVACY PRACTICES

NOTICE 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. I. What This Is

More information

Person to Contact in Case of Emergency. THE COUNSELING PLACE YOUTH INTAKE FORM Yearly Family Income:

Person to Contact in Case of Emergency. THE COUNSELING PLACE YOUTH INTAKE FORM Yearly Family Income: Person to Contact in Case of Emergency Name Relationship Best Contact Number Alt. Number Office Use Only Intake Date Reason for referral Counselor Who Can Pick Up Client (if Minor) THE COUNSELING PLACE

More information

NOTICE OF PRIVACY PRACTICES

NOTICE 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. WHY ARE YOU GETTING

More information

Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. Collom & Carney Clinic Association NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES EFFECTIVE DATE: APRIL 14, 2003 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

More information

If you have any questions about this notice, please contact the SSHS Privacy Officer at:

If you have any questions about this notice, please contact the SSHS Privacy Officer at: Notice of Privacy Practices 0 Effective Date: April 14, 2003 Revision Date: July 15, 2016 South Shore Health System ( SSHS ) is an integrated health care delivery system. For a list of entities which comprise

More information

NEW CLIENT INFORMATION SHEET. Thank you for choosing Elledge Counseling Associates for your counseling needs. The following pages contain:

NEW CLIENT INFORMATION SHEET. Thank you for choosing Elledge Counseling Associates for your counseling needs. The following pages contain: NEW CLIENT INFORMATION SHEET Thank you for choosing Elledge Counseling Associates for your counseling needs. The following pages contain: Directions to the Counseling Center Personal Information Data Form

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES 535 East 70th Street New York, NY 10021 (212) 606-1000 Specialists in Mobility NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE

More information

JOINT NOTICE OF PRIVACY PRACTICES

JOINT NOTICE OF PRIVACY PRACTICES JOINT 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. respects

More information

SUMMARY OF THE CIRCUMSTANCES AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED

SUMMARY OF THE CIRCUMSTANCES AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED 374 Hudlow Road, Post Office Box 336 Forest City, NC 28043 Phone: (828) 245-0095 FAX: (828) 248-1035 Toll Free: 1-800-218-CARE (2273) HOSPICE OF RUTHERFORD COUNTY PRIVACY PRACTICES THIS NOTICE DESCRIBES

More information

Your Rights and Responsibilities as a Patient at Sparrow Hospital

Your Rights and Responsibilities as a Patient at Sparrow Hospital Your Rights and Responsibilities as a Patient at Sparrow Hospital Sparrow s mission is to improve the health of the people in our communities by providing quality, compassionate care to every person, every

More information

HIPAA Privacy Rule and Sharing Information Related to Mental Health

HIPAA Privacy Rule and Sharing Information Related to Mental Health HIPAA Privacy Rule and Sharing Information Related to Mental Health Background The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule provides consumers with important privacy rights

More information

Beck & Blackley Chiropractic Clinic

Beck & Blackley Chiropractic Clinic Address City State Zip Code Home Phone Cell Phone Work Phone Email Address Sex: M F Marital Status: M S D W Date of Birth SS# Spouse Name How did you hear about our office? Employer Name/Occupation Emergency

More information

Dr. Kristin Heins, ND Thrive Natural Family Health 110 Eglinton Avenue East, Suite 502 Toronto, Ontario M4P 2Y1 Telephone: (647)

Dr. Kristin Heins, ND Thrive Natural Family Health 110 Eglinton Avenue East, Suite 502 Toronto, Ontario M4P 2Y1 Telephone: (647) Psychotherapy Client Information Today's date: A. Identification Your name: Date of birth: Age: Your nicknames/previous/maiden/aliases: Sex: [ ]Male [ ]Female Gender: Title: [ ]Mr. [ ]Mrs. [ ]Miss [ ]Ms

More information

Navigating Work Life Health. Affiliate Clinical Forms

Navigating Work Life Health. Affiliate Clinical Forms Navigating Work Life Health Affiliate Clinical Forms Introduction Lytle EAP Partners is an independent consulting and service organization that provides development, implementation, and administration

More information

PATIENT NOTICE OF PRIVACY PRACTICES Effective Date: June 1, 2012 Updated: May 9, 2017

PATIENT NOTICE OF PRIVACY PRACTICES Effective Date: June 1, 2012 Updated: May 9, 2017 PREMIER PSYCHIATRY Psychiatric and Behavioral Health Services PATIENT NOTICE OF PRIVACY PRACTICES Effective Date: June 1, 2012 Updated: May 9, 2017 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU

More information

Healing Path Counseling Center

Healing Path Counseling Center Healing Path Counseling Center Main Office: 603 Old Liberty Rd. STE 1. Sykesville, MD 21117 Phone: 410-921-9004 Email: healingpathcounselingcenter.com Rachel Cochran LCSW-C CLIENT INTAKE FORM PERSONAL

More information

Parental Consent For Minors to Receive Services

Parental Consent For Minors to Receive Services Parental Consent For Minors to Receive Services Welcome to the University of San Diego s Wellness Area! We appreciate your coming our way, and look forward to working with you. The following provides important

More information

Counseling Center of Montgomery County

Counseling Center of Montgomery County Counseling Center of Montgomery County 212 Conroe Drive (936) 760-1880 Office Conroe, TX 77301 (936) 760-2915 Office CCMC@CounselingCenterMoCo.com (936) 760-9101 Fax CHILD/ADOLESCENT PSYCHOSOCIAL HISTORY

More information

CAPITAL SURGEONS GROUP, PLLC

CAPITAL SURGEONS GROUP, PLLC CAPITAL SURGEONS GROUP, PLLC 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

More information

Dr. Kinsler & Associates, LLC Help when life hurts

Dr. Kinsler & Associates, LLC Help when life hurts Dr. Kinsler & Associates, LLC Help when life hurts PREMARITAL COUNSELING INTAKE Bride s Name: WEDDING DATE: Age: Birthdate: Birthplace: Address: City: State: Zip: Phone: Highest level of education (grade/degree):

More information

PATIENT INFORMATION Indiana Plastic Surgery Center, PC

PATIENT INFORMATION Indiana Plastic Surgery Center, PC PATIENT INFORMATION DATE: / / PHYSICIAN REFERAL: FAMILY/FRIEND REFERAL: PRIMARY CARE PHYSICIAN: LAST NAME FIRST M.I. HOME ( ) - CELL( ) - WORK( ) - EMAIL MAY WE CONTACT YOU: BY CELL PHONE / TEXTING?: YES

More information

Behavioral Health Services

Behavioral Health Services PeaceHealth Medical Group 1200 Hilyard St., Suite 460 1200 Hilyard St., Suite 420 4010 Aerial Way 3333 RiverBend Eugene, OR 97401 Eugene, OR 97401 Eugene, OR 97402 Springfield, OR 97477 (541) 685-1794

More information

Balance Fitness and Nutrition

Balance Fitness and Nutrition Balance Fitness and Nutrition HIPPA Notice of Privacy Practices Effective Date: January 29, 2012 THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES NOTICE OF PRIVACY PRACTICES Effective Date: July 12, 2017 THIS NOTICE OF PRIVACY PRACTICES ( NOTICE ) DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO

More information

Therapist Disclosure Statement & Client Informed Consent

Therapist Disclosure Statement & Client Informed Consent Therapist Disclosure Statement & Client Informed Consent Radka Chapin, MA, MSW, LICSW Radka Chapin Counseling, PLLC 1611 116 th Ave NE, Suite 119, Bellevue, WA 98004 http://radkachapin.com/ Washington

More information

Friendswood Counseling Center, LLC Phone: (479) E. FM 528 Rd, Suite 200 Fax: (281) Client Registration

Friendswood Counseling Center, LLC Phone: (479) E. FM 528 Rd, Suite 200 Fax: (281) Client Registration Friendswood Counseling Center, LLC Phone: (479) 200-6034 3526 E. FM 528 Rd, Suite 200 Fax: (281) 819-7845 Friendswood, TX 77546 Email: kristi@friendswoodcc.com Website: www.friendswoodcc.com Client Registration

More information

Atascocita Counseling Associates Krissy Cotten, MA, LPC. Adult New Client Profile

Atascocita Counseling Associates Krissy Cotten, MA, LPC. Adult New Client Profile Adult New Client Profile Please complete the following as accurately and as completely as possible. Social Security Number is required only if you are filing with insurance. Today s Date: Name: Date of

More information

BON SECOURS RICHMOND NOTICE OF PRIVACY PRACTICES

BON SECOURS RICHMOND NOTICE OF PRIVACY PRACTICES BON SECOURS RICHMOND 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 CAREFEULLY.

More information

Notice of Health Information Privacy Practices Acknowledgement

Notice of Health Information Privacy Practices Acknowledgement I understand that as part of my healthcare, Sonoma Valley Hospital and its medical staff creates, receives and maintains health records describing my health history, symptoms, examination and test results,

More information

NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES BUTTE COUNTY DEPARTMENT OF BEHAVIORAL HEALTH NOTICE OF PRIVACY PRACTICES Effective Date: 4/14/2003 THIS NOTICE DESCRIBES NOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

More information

INFORMED CONSENT FOR TREATMENT

INFORMED CONSENT FOR TREATMENT INFORMED CONSENT FOR TREATMENT I (name of client) agree and consent to participate in behavioral healthcare services offered and provided by Methodist Services - Community Counseling Services (CCS). I

More information

Julie Berger, MS, NCC, LPC HOLY FAMILY COUNSELING CENTER Peachtree Industrial Blvd. Suite 120, Duluth, GA INTAKE FORM

Julie Berger, MS, NCC, LPC HOLY FAMILY COUNSELING CENTER Peachtree Industrial Blvd. Suite 120, Duluth, GA INTAKE FORM INTAKE FORM We welcome you to our faith-based practice. It is our goal to help you through the difficulties you are experiencing by addressing the whole person and family with dignity. Our goal as your

More information

Patient Consent Form

Patient Consent Form Alexander Raskin, M.D., Q.M.E. Assistant Clinical Professor UCLA School of Medicine ORTHOPEDIC SURGERY SPORTS MEDICINE ARTHROSCOPY 16311 Ventura Blvd., Suite 1150, Encino, CA 91436 T (818) 788-ORTHO (6784)

More information

FORENSIC COUNSELING SERVICES Aaron Robb, Ph.D. Program Director Mailing address: 2831 Eldorado Pkwy, Ste , Frisco, TX 75033

FORENSIC COUNSELING SERVICES Aaron Robb, Ph.D. Program Director Mailing address: 2831 Eldorado Pkwy, Ste , Frisco, TX 75033 FORENSIC COUNSELING SERVICES Aaron Robb, Ph.D. Program Director Mailing address: 2831 Eldorado Pkwy, Ste. 103-377, Frisco, TX 75033 Telephone: 972-360-7437 Interview office: 250 N. Mill St. Suite 5, Lewisville

More information

Cadenza Center for Psychotherapy & the Arts, Inc. ADULT INTAKE

Cadenza Center for Psychotherapy & the Arts, Inc. ADULT INTAKE Cadenza Center for Psychotherapy & the Arts, Inc. ADULT INTAKE Date: / / Name: Date of Birth: / / Age: Sex: M F ETHNIC ORIGIN: White Hispanic Haitian African American Other: PRIMARY LANGUAGE: English Spanish

More information

ADVANCED PLASTIC SURGERY, PLLC. NOTICE OF PRIVACY PRACTICES

ADVANCED PLASTIC SURGERY, PLLC. NOTICE OF PRIVACY PRACTICES Effective Date: July 1 st 2013 ADVANCED PLASTIC SURGERY, PLLC. NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO

More information

FAMILY PHARMACEUTICAL SERVICES NOTICE OF PRIVACY PRACTICES effective 9/23/2013

FAMILY PHARMACEUTICAL SERVICES NOTICE OF PRIVACY PRACTICES effective 9/23/2013 FAMILY PHARMACEUTICAL SERVICES NOTICE OF PRIVACY PRACTICES effective 9/23/2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

More information

Notice of privacy practices

Notice 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. Our staff are committed

More information

Patient s Bill of Rights (Revised April 2012)

Patient s Bill of Rights (Revised April 2012) Patient s Bill of Rights (Revised April 2012) TIRR Memorial Hermann recognizes the rights of human beings for independence of expression, decision, and action and will protect these rights of all patients,

More information

CHAPTER 411 DIVISION 20 ADULT PROTECTIVE SERVICES -- GENERAL

CHAPTER 411 DIVISION 20 ADULT PROTECTIVE SERVICES -- GENERAL CHAPTER 411 DIVISION 20 ADULT PROTECTIVE SERVICES -- GENERAL 411-020-0000 Purpose and Scope of Program (Amended 11/15/1994) (1) The Seniors and People with Disabilities Division (SDSD) has responsibility

More information

PATIENT INFORMATION Please Print

PATIENT INFORMATION Please Print PATIENT INFORMATION Please Print DATE Patient s Last Name First Name Middle Name Suffix Gender: q Male q Female Social Security Number of Birth Race Ethnic Group: q Hispanic q Non-Hispanic q Unknown Preferred

More information