Consent Form - Healthy Living Psychology Group

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CONSENT FOR TREATMENT/HIPAA/OFFICE POLICY ACKNOWLEDGEMENT

* Please be sure to read the HIPAA and Service Agreement forms first.

Patient’s full Name *

Phone Number *

Date of Birth *

Street Address *

City *

State *

Zip Code *

Contact Permission

Mobile Phone *

E-Mail *

Physician’s Name *

Physician’s Phone *

Physician Street Address *

City *

State *

Zip Code *

Physician Fax *

EMERGENCY CONTACT

Full Name *

Relation to Patient *

Phone Number *

INSURANCE DISCLAIMER:
HLPG assumes no liability for any benefit information that is misquoted by your insurance carrier. It is your ultimate responsibility to be aware of your insurance coverage, limitation, and terms and conditions of your policy. Benefits and verification are performed as a courtesy to you. HLPG cannot be responsible for any information that is obtained directly from your insurance carrier that is later deemed inaccurate. You are responsible for payment of any deductible, co-payment and co-insurances as determined by your policy.

MY SIGNATURE BELOW INDICATES THAT I UNDERSTAND AND AGREE TO THE TERMS OF THE SERVICE AGREEMENT REVISED 03/18 AND ACKNOWLEDGES THAT I HAVE RECEIVED THE HIPAA NOTICE DESCRIBED THEREIN

SIGN YOUR FULL NAME *

By clicking "Submit", I consent to the following forms of communication from HLPG: Email, Text, Surveys, and Promotions. *

CONSENT FOR TREATMENT/HIPAA/OFFICE POLICY ACKNOWLEDGEMENT

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