paymnt - Chicago Psychological

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Where Cognition meets Positive Change.

Chicago Psychological

Chicago Psychological welcomes you to a practice of professionals recognized by national professional organization with specialization in the field of psychological and behavioral health. We believe in treating you with trust and respect, providing compassionate and competent therapeutic services.

Monday to Friday 10:00 am – 7:00 pm

Questions? Call us!

401 North Michigan Avenue
Suite # 1200
Chicago IL 60611

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
Hidden
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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Payment form

Where Cognition meets Positive Change.

Chicago Psychological

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HIPAA Authorization V2