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HIPAA Authorization V2
I have been given and read the Agreement (Therapist-Patient Agreement with Chicago Psychological (Dated January 1, 2010) and I agree to its terms.
Printed Name of the Patient
*
First
Last
Signed Date:
*
Date Format: MM slash DD slash YYYY
Signature of the Adult if Patient
_______________
Date Signed
_______________
Signature of Minor Client (if age 12-17):
_______________
Date Signed
_______________
Signature of Legal Guardian for Minor Client:
_______________
Date Signed
_______________
Consent
I acknowledge the receipt of HIPAA Notice.
I acknowledge that I have received the HIPAA Notice Form (Notice of Chicago Psychological Policies and Practices to Protect the Privacy of Your Health Information).
Printed Name of the Client
*
Full Name
Signed Date:
Date Format: MM slash DD slash YYYY
Signature of the Adult if Client
_______________
Date Signed
_______________
Signature of Minor Client (if age 12-17):
_______________
Date Signed
_______________
Signature of Legal Guardian for Minor Client:
_______________
Date Signed
_______________
Send me the PDF to be signed to this E-mail address
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