New Client: Adult
In order to help save you time, please complete all forms below and bring with you to your first appointment. Thank you!
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES - HIPPA
I understand that as part of my healthcare, Stephen Terrell originates and maintains health records describing my health history, symptoms, evaluations and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals.
The Notice of Privacy Practices provides specific information and thorough description of how my personal health information may be used and disclosed. I have been provided a copy of or access to the Notice of Privacy Practices and understand that I have been given an opportunity to review the Notice prior to signing this consent. I understand that I will be given a copy of any future revisions of the Notice of Privacy Practices. I understand that I have the right to restrict the use and/or disclosure of my personal health information for treatment, payment, or healthcare operations and that Stephen Terrell is not required to agree to the restrictions requested. I may revoke this consent at any time in writing except to the extent that Stephen Terrell has already taken action in reliance on my prior consent. This consent is valid until revoked by me in writing.
I have been provided and have received The Notice of Privacy Practices.
____________________________________________________________ _____________________ Signature of Client Date
I further give my permission for Terrell to contact me in the following ways (initial all that apply):
_____By phone leaving detailed message
_____By phone leaving no identifying information
_____By mail with return address
_____By mail leaving no identifying information
_____Through emergency contact person
_____No contact is allowed
By checking the box I agree that the signature I have entered above will be the electronic representation of my signature and initials for all purposes when I use them on documents, including legally binding contracts – just the same as a pen-and-paper signature.