The Fine Print
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT
Welcome to my practice! This document collects some of the important information about how my practice works. I give a copy of this to new clients, and it is also on my website. It serves as a document about informed consent, and includes the HIPAA information I’m required to give you. Your signature on the Consent to Treatment indicates that you accept all of these terms; if you wish to revoke that consent any time after having signed it, simply let me know and we will discuss how to proceed. This is, unfortunately, a long document, but I will have to assume you know what is in it should any of the situations discussed in it arise.
PSYCHOLOGICAL SERVICES INFORMED CONSENT:
Therapy is part art and part science, and I use both aspects, depending on what you need. It is a particular kind of professional relationship in which you and I meet for the purpose of helping you resolve obstacles to living a satisfying and fulfilling life. Therapy works best when sessions serve as catalysts for work you do outside of session, whether it is thinking differently about problems, trying different behaviors, keeping particular kinds of records that I may need, or talking with your loved ones about particular aspects of our work. I use a lot of educational materials and may refer to you various resources to learn more about whatever it is that is causing you problems, as well as helping to teach and support you in session.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable emotions like sadness, guilt, anger, frustration, loneliness, anxiety and helplessness. These feelings may occur during sessions and also after you leave. You will not necessarily enjoy coming to sessions during some parts of treatment, because of the emotional difficulty in talking about your issues. Other people in your life may not be happy with the changes you decide to make, which can cause problems in relationships. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. Even if you do your best, and I do mine, therapy does not always “work”. However, part of therapy is re-evaluating what is working and what is not, and there is no reason to continue indefinitely in therapy that you don’t think is helpful. I respect your time, energy and money, and am willing to help you evaluate along the way whether the work we are doing appears to be on course. If we aren’t a good match, I’m happy to help you find someone else who might fit your needs better.
Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with whether you feel comfortable working with me. Therapy involves a significant commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. I like to be transparent in my methods and am always willing to explain to you why I’m asking about particular issues or what I think may be going on. I am equally committed to transparency with my billing, which I do myself, and encourage you to ask questions whenever you may have them about your copay or balance.
I will conduct an initial assessment, which lasts an hour and costs $200. During this time, and over the next several sessions, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. After the first session, we will schedule sessions lasting 45 minutes each, and which cost $125 per session. We will decide early in treatment how often it would be best if you came; many people start with weekly or every other week sessions and then reduce the frequency as they improve. If you have insurance with which I don’t have a contract, I am allowed to bill you the difference between what they pay and what I charge, and I will discuss with you whether you would like to do an hour session instead (also $125). I can’t do that when I am in-network, so we will have to stay with 45 minute sessions in that case.
CANCELLATION FEES: Because an unplanned empty session represents a significant loss of income, most therapists have some kind of policy to help mitigate their costs. I have developed what I think is a fairly liberal cancellation policy. Please feel free to discuss it with me if you think it will not work for you. An appointment cancelled after 9:00 a.m. the day of a session will be assessed a $30 fee, unless I can fill the session, in which case there will be no charge. A session that is missed without cancelling may be charged at my full rate, $125, because I will have no chance to fill it, unless there are extraordinary circumstances, or a clear misunderstanding about the appointment time that resulted in missing the session. These fees are not covered by insurance, and will be expected at the next session unless other arrangements are made. I will not charge for late cancellations due to severe weather, and may cancel those sessions myself if it looks like it may be dangerous to be on the roads. I also will not charge for extraordinary circumstances which require you to miss a session without notice, such as you or a family member being hospitalized.
My hourly and session fee is $125. In addition to weekly appointments, I charge this amount for other professional services you may need. Other services may include report writing, telephone conversations lasting longer than 15 minutes, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. I often use e-mail between sessions, and will not charge for that except under unusual circumstances. Insurance will not cover services other than a standard session, including phone sessions. Your signature on the Consent to Treat indicates that you understand that insurance will not pay for anything other than face-to-face office therapy, and that you are responsible for those fees. This specifically includes Medicare and Blue Cross.
I am difficult to reach by phone. I have confidential voice mail, but I often do not check it more than once a week. I am much more available by e-mail, and if you are comfortable with the confidentiality risks inherent in the use of the internet, I am happy to use that for business-related or clinical issues between sessions. I have provided a sheet entitled “How to Contact Me” with details on how to reach me outside of session
If you are unable to reach me and feel that you can’t wait for me to return your call, contact your physician or the nearest emergency room and ask for the psychiatrist on call or the Crisis Team. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary, but I am generally available by e-mail even when I am on vacation, if you have an urgent concern. We will discuss a clear plan for what you should do if you have an emergency and can’t reach me right away. If you are someone who needs to know their therapist is reachable in a crisis, I might not be the best person for you; I’m not a “first responder” in my practice, although I’m more than willing to work with other providers if you were to have a crisis and need hospitalization, for instance.
MORE ABOUT E-MAIL: I find that it is often helpful to use e-mail between sessions, to confirm appointments, reschedule, cancel, or to briefly follow up on issues raised in session which may be bothering you enough that you don’t want to wait until the next session. It is useful if you want to provide me with information to read outside of session, and I also use it to recommend books, websites, and other resources. I may also use it for brief, specific behavioral coaching if we are working on learning and using new skills that you need to practice outside of sessions. I will contact you using encrypted e-mail, which will require you to enter the answer to a simple question as a password. I will assume that you consent to my using e-mail for communications related to appointments or billing, unless you tell me otherwise. Any e-mails between us will be stored only in an encrypted form by a HIPAA-compliant company, and will not be on my hard drive or anywhere else where it might be breached.
It is your responsibility to determine what mental health coverage your insurance provides, and you will be responsible for anything it does not pay, even if there is a misunderstanding and charges you expected would be covered turn out not to be. This is often an awkward and uncomfortable situation, because you may feel you cannot continue treatment if something goes wrong with your insurance. Although I am likely to be uncomfortable too, I must ask that you take responsibility for whatever charges are not covered.
If you have questions about the coverage, call your plan administrator at Human Resources, or call the number on the back of your card. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company.
I am only in-network for Blue Cross/Blue Shield. If I don’t take your plan, I can sometimes be covered as an "Out of Network provider", depending on your policy. I take Medicare Advantage plans, but do not take Medicaid. The co-pay or co-insurance for an out-of-network plan ranges from reasonable to outrageous, and sometimes there is a deductible as well.
ALWAYS check with your insurance to see whether I am a provider, even if you think you know. You can have an HMO Blue Cross policy which “carves out” mental health benefits to a different company, such as Magellan, United Behavioral Health, or Teamsters. Even though I am a provider for Blue Cross, I am not a provider for the “carve out” companies, and they may not pay. You will not know whether you have a “carve out” unless you call the number for mental health on the back of your insurance card and ask whether I am a provider for your plan. We might consider who benefits if people are misled about their benefits and the insurance company doesn’t have to pay…but I digress.
Unfortunately, during the course of treatment your insurance may change to one that I can’t take. We will then have to discuss whether you would rather see me while paying my full fee, whether a short-term arrangement for a reduced fee would carry you until your insurance changes again, or whether you need a referral to someone who does take your insurance.
You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis, dates and times of sessions, and other information which varies by policy. Companies which do “reviews” of services often ask very intrusive and personal questions, and may refuse benefits even if I provide them with that information. I make every effort to release only the minimum information about you that is necessary for the purpose requested, and I only keep a minimum of clinical information in my records. Requested information will become part of the insurance company files and will be stored in a database, which is supposed to be secure, but over which I have no control. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report or letter I submit, if you request it, and will tell you if I am asked to do a more extensive “review”. By signing the consent, you agree that I can provide requested information to your carrier.
Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. You always have the right to pay for my services yourself to avoid the problems described above. I am more than willing to help you figure out how to maximize benefits, and will provide receipts for Flexible Spending Account reimbursement upon request.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communication between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require that you provide written, advance consent.
I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I will not reveal your identity. The other professionals are also legally bound to keep any shared information confidential. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
There are some situations where I am required to disclose information without your consent, as listed on the Consent for Treatment:
- If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-client privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information (and please see my guidelines below about my court involvement in your case).
- If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client, in order to defend myself.
- If a client files a worker’s compensation claim, I must, upon appropriate request, provide appropriate information, including a copy of the client’s record, to the client’s employer, the insurer, or the Department of Worker’s Compensation.
If I have reasonable cause to believe that a child under age 18 is suffering physical or emotional injury resulting from abuse inflicted upon him or her which causes harm or substantial risk of harm to the child's health or welfare (including sexual abuse), or from neglect (including malnutrition), the law requires that I file a report with the Department of Children and Families. Once such a report is filed, I may be required to provide additional information. This is true even if it is your child or a child in your extended family, and I have no choice about making a report once information about probable abuse or neglect is given to me. Please carefully consider what information you choose to give me in sessions about such things, because the law does not allow me any leeway for personal discretion, and I can be prosecuted or lose my license if I fail to report disclosed information.
If I have reason to believe an elderly or disabled individual is suffering from abuse by caretakers, the law requires that I report to the Department of Elder Affairs or the Disabled Persons Protection Commission. Once such a report is filed, I may be required to provide additional information. Again, I have no choice about making such a report once I have the information, even if you and I believe that disclosing the information would be to your detriment.
If you communicate an immediate threat of serious physical harm to an identifiable victim or if you have a history of violent behavior and the apparent intent and ability to carry out the threat, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, and/or seeking hospitalization for you.
If you tell me that you are seriously considering suicide, I may be obligated to seek hospitalization for you, or to contact family members or others who can help provide protection. This is particularly true if I believe you are at immediate risk of serious harm to yourself, and if you have a plan and the means to carry out the plan. This is true even if you refuse to be hospitalized or refuse permission for me to speak to others. However, if there is no immediate risk, or if it is risk of self-injury that is not potentially lethal I am not allowed to break confidentiality. Please tell me if you are feeling suicidal, or more suicidal than usual, or if you are thinking of hurting yourself in any way, and we will figure out what the best thing to do will be. I do not break confidentiality lightly, and I am very reluctant to initiate involuntary hospitalization unless I have absolutely no other way of protecting your safety. If I have to, though, I will.
If any of these situations arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future.
The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in your Clinical Record. Your record includes such information as the issue which brought you to treatment, history related to your treatment, a treatment plan, notes including the date and length of sessions and your progress, and copies of your authorizations for treatment and for disclosure of PHI. It will also contain billing information, demographic information and may contain letters or reports that I request from other treaters. You may examine and/or receive a copy of your records if you request it in writing, unless I believe that access would endanger you. In those situations, you have a right to a summary and to have your record sent to another mental health provider or your attorney. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence. In most situations, I am allowed to charge a copying fee of $1.00 per page. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon your request. My records tend to include only the minimal information needed to provide proof of medical necessity and the time and type of treatment, because I believe that provides the most confidentiality to my clients.
HIPAA provides you with rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. If you have a copay, I will expect that you pay it at each session. For ongoing clients, I may be willing to negotiate a sliding scale for limited periods of treatment should your financial or insurance situation change in a way that impacts treatment. I do not generally start off with a sliding scale for new clients, and I don’t expect that a sliding scale for ongoing clients will be long-term, but in some cases it is preferable to interrupting or ending treatment prematurely.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.]
If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party or if I arrive at court and the session is continued, or my services turn out not to be needed. Because of the difficulty of legal involvement, I charge $150 per hour for transportation, preparation and attendance at any legal proceeding. This is true for any kind of legal proceeding, including those related to divorce, custody, personal injury, criminal charges, or any other kind of legal involvement.
In general, I strongly prefer not to be involved in court proceedings, because I find that it compromises the therapeutic relationship, sometimes irreparably. Also, I find that I’m not at my most effective in court and my participation may not help you, even though I would want it to. If I have to go to court for you, or am forced to testify by another party, we may not be able to continue therapy afterwards. If you are currently involved in legal proceedings which are likely to involve testimony by your therapist, I can help you find therapists who enjoy and are good at advocating for their clients in that way.
Something to be aware of is that your therapist cannot ethically testify as your treating therapist and as an expert witness for a case at the same time, although attorneys often would like that to happen. I am not an expert in any area, legally, so I could only participate in terms of saying what occurred in sessions, my diagnosis, etc. I cannot offer opinions about what might be best for you, your children, or anyone else in your legal situation.
Obviously, sometimes legal issues come up during the course of therapy. I am of course willing to respond to requests should you have an attorney or a GAL who needs information about your treatment. But if you know in advance there might be legal involvement, I’m not the best person to work with you.
FINALLY: With all those caveats, I would like to say that therapy can be an incredible gift to yourself and your loved ones. While problems can often resolve themselves over time, working on them with a trained, experienced partner can greatly reduce the time it takes for you to move onto a more satisfying life. I am mindful of the commitment you make in terms of scheduling time, dealing with payment or insurance, and in agreeing to talk about difficult issues and work with them outside of sessions. I will do everything I can to be helpful and efficient in addressing the issues which bring you to therapy. Please ask me if you aren’t sure what we’re doing, why we’re doing it or whether it’s working—those are not unusual questions in the course of therapy, and they are entirely appropriate. I look forward to joining you on your journey.
NOTICE OF PRIVACY POLICIES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION
This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information.
Please read it carefully!
I. Uses and Disclosures for Treatment, Payment and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
· “PHI” refers to information in your chart that could identify you.
· “Treatment, Payment and Health Care Operations”
Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your PCP or another therapist.
Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters, such as audits and administrative services, and case management and case coordination.
Use applies to activities within my practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
Disclosure applies to activities outside of my practice, such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your chart. These notes are given a greater degree of protection than PHI. It is PANR’s policy not to keep separate psychotherapy notes. All documentation we keep is a part of your clinical chart.
I will also obtain an authorization from you before using or disclosing PHI in a way that has not been described in this notice.
I will not use your PHI for marketing or sales purposes under any conditions.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
· Child Abuse: If I, in my professional capacity, have reasonable cause to believe that a minor child is suffering physical or emotional injury resulting from abuse inflicted upon him or her which causes harm or substantial risk or harm to the child’s health or welfare (including sexual abuse), or from neglect, including malnutrition, I must immediately report such a condition to the Massachusetts Department of Children and Families.
· Adult and Domestic Abuse: If I have reasonable cause to believe that an elderly person (age 60 or older) is suffering or has died as a result of abuse, I must immediately make a report to the Massachusetts Department of Elder Affairs.
· Health Oversight: The Board of Registration that applies to my particular license to practice has the power, when necessary, to subpoena relevant records should I be the focus of an inquiry.
· Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and I will not release information without written authorization from you or your legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the court evaluation is court ordered. You will be informed in this case.
· Serious Threat to Health or Safety: If you communicate to me an explicit threat to kill or inflict serious bodily injury upon an identified person and you have the apparent intent and ability to carry out the threat, I must take reasonable precautions. Reasonable precautions may include warning the potential victim, notifying law enforcement, or arranging for your hospitalization. I must also do so if I know you to have a history of physical violence and I believe there is a clear and present danger that you will attempt to kill or inflict bodily injury upon an identified person. Furthermore, if you present a clear and present danger to yourself and refuse to accept further appropriate treatment and I have a reasonable basis to believe that you can be committed to a hospital, I must seek said commitment and may contact members of your family or other individuals if it would assist in protecting you.
· Workers Compensation: If you file a worker’s compensation claim, your records relevant to that claim will not be confidential to entities such as your employer, the insurer and the Division or Worker’s Compensation.
When the use and disclosure without your consent or authorization is allowed under sections of Section 164.512 of the Privacy Rule and the state’s confidentiality law, this includes certain narrowly defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
IV. Patient’s Rights and Mental Health Clinician’s Duties
· Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.
· Right to Receive Confidential Communications by Alternative Means and Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address).
· Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases, you may have the decision reviewed. On your request, I will discuss with you the details of the amendment process.
· Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.
· Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.
· Right to a Paper Copy: You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
· Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket: You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket or in full for my services.
· Right to Be Notified if There is a Breach of Your Unsecured PHI: You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.
Mental Health Clinician’s Duties:
· I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
· I reserve the right to change the privacy policies and practices described in the notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will notify current clients and post the new policies in the waiting area.
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you should talk with me. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.
This notice will go into effect September 9th, 2013. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will notify current clients of changes in person or by mail and closed client cases can, if interested, call and ask if our policies have changed and obtain a copy by mail or view one in our waiting area.
Lynda L. Warwick, Ph.D.
PO Box 155
Dunstable, MA 01827
CONSENT TO USE AND DISCLOSE YOUR HEALTH INFORMATION
This form is an agreement between you ___________________________ and Lynda L. Warwick, Ph.D.
When I examine, diagnose, treat, or refer you I will be collecting what the law calls Protected Health Information (PHI) about you. I need to use this information here to decide on what treatment is best for you and to provide treatment to you. I may also share this information 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 that you have read and understand my Notice of Privacy Policies and you are agreeing to let me use your information here and send it to others in accordance with our written policies. Please make sure you have read and understand our Privacy Policies above before signing this Consent form.
If you do not sign this consent form agreeing to what is in our Notice of Privacy Policies, we cannot treat you.
In the future I may change how I use and share your information and so may change my Notice of Privacy Policies. If I do change it, you can get a copy from my website: www.lyndawarwick.com or by calling us at 978 452-3711, x4, or by requesting it via e-mail at firstname.lastname@example.org.
If you are concerned about some of your information, you have the right to ask me not to use or share some of your information for treatment, payment, or administrative purposes. You will have to tell me what you want in writing. Although I will try to respect your wishes, I am not required to agree to these limitations. However, if I do agree, I promise to comply with your wish.
After you have signed this consent, you have the right to revoke it (by writing a letter telling me you no longer consent) and I will comply with your wishes about using or sharing your information from that time on. However, we may already have used or shared some of your information and cannot change that.
Signature Printed name of client or personal representative
Date of Signature Date NPP received by client or representative