paymnt - Chicago Psychological

Payment form

Name

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Cardholder Name(Required)

First Last

Email(Required)

Billing Address

Street Address Address Line 2 City State ZIP Code

Amount of payment being made(Required)

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Total Amount to be Charged

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Invoice No (If available)

Credit Card(Required)

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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
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Signed Date:*
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:
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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