Archive for March, 2012

Mar 06 2012

HIPPA Signature Page

Please sign this form to show I have given you the HIPPA privacy notice, given you a chance to read it, and discussed the important points of the law and given you a chance to ask any questions.

 

I have read the above Office Policies and General Information, Agreement for Psychotherapy Services or Informed Consent for Psychotherapy carefully (a total of 7 pages); I understand them and agree to comply with them:

 

Client’s Name (print) ______________________________________________                                                          

 

Signature ___________________________________________

Date ___________________

 

 

Client’s Name (print) ______________________________________________

 

Signature ___________________________________________

Date ___________________

 

 

Psychotherapist’s Name (print) _____William F. Martin_______________________

 

 

Signature __William F Martin, LCSW ________________________

Date ___________________                                                                    

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