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CONSENT FOR TREATMENT

 

CONSENT TO USE AND DISCLOSE HEALTH INFORMATION

 

I have received a “Client Handbook” that, among other things, details information concerning my privacy rights and I agree with the terms stated therein.  I consent to psychotherapeutic treatment by Dr. Brian M. Campbell, a licensed psychologist.  This form is an agreement between you and Dr. Brian Campbell.  For the purposes of this consent form, the word "you" below may refer to you, your child, or a relative.

 

I understand that I am financially responsible for all charges incurred.  I hereby authorize the assignment of insurance benefits, if applicable, to New Life Christian Counseling Center, Inc.  I also authorize New Life Christian Counseling Center, Inc. to release any information necessary for the processing of claims.

 

I am aware that Dr. Campbell’s office requires a 24-hour cancellation notice and I will be billed if I do not keep an appointment and fail to give 24-hour notice, and there are clients waiting to schedule.  (Also, see, Appointment Letter).

 

This consent form is required, according to Federal HIPAA regulations, for me to provide services.  It documents my agreement with the NPP form, contained in the “Client Handbook.”

 

When I, or anyone associated with this office, provide examination, testing, diagnosis, treatment, or a referral for you, this will include the collection of what the law called Protected Healthcare Information (PHI) about you.  This information is necessary in order to decide what treatment is best and to provide it.  This information may be shared with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions.  By signing this form, you are agreeing to allow the use of your information here or with others as is explained in more detail in the Notice of Privacy Practices (NPP).  It also details your rights.  Your consenting to this form approves the practices detailed in the NPP summary and full NPP (a copy of which is available in the front office). 

 

In the future, I may change some of these policies.  If so, it would be described in a new NPP.  You can get a copy by asking me by phone or in writing.  If you have concerns about some of your information, you have the right to ask me to not use or share some of your information for treatment, payment, or administrative purposes.  You would have to communicate in writing what you are asking.  After receiving it, although I am not required to agree to the request, I would let you know if I can agree with the limitations.  If I agree, I will do my best to do as you asked.  

 

After you have signed this consent, you have the right to revoke it by writing a letter to me in my role of Privacy Officer, informing me that you no longer consent.  I would no longer be able to provide treatment, because of the requirement of me to have a signed consent form in order to provide services.  If I receive such a revocation of this consent, I will comply with your wishes about using or sharing your information from that time on but I may already have used or shared some information in accord with this consent and of course would not be able to change that.

 

 

________________________________________________                _______________________

        (Signature of Client or his/her Representative)                                              (Date)

 

                                              

________________________________________________        ___________________________

         (Printed Name of Client or his/her Representative)                    (Relationship to Client)

 

                  

________________________________________________________   ______________________

  (Witness:  Signature of Authorized Representative of this Practice)     (Date Handbook Provided)