If you want to schedule an appointment, please contact our office at , so we can discuss the most appropriate options for you. Please complete this paperwork to the best of your ability at least 24 hours prior to your appointment, so your clinician can review it before they meet with you. To protect your information and verify your identity when using this form, we require you to upload a picture of a photo ID card driver's license, student ID, etc.
Note: Responses to this paperwork are not monitored in real-time. Welcome to our practice. This document the Agreement contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act HIPAA , a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information PHI used for the purpose of treatment, payment, and health care operations.
The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging we provided you with this information at the end of the initial session.
Although these documents are long and sometimes complex, it is very important that you read them carefully before your session. You and your professional can discuss any questions you have about the procedures at that time.
When you sign this document, it will also represent an agreement between you, ATAGF, and your professional. Individuals who are Licensed Psychologists have a PhD in Clinical or Counseling Psychology and have completed the requirements for licensure as a psychologist in the state of North Dakota.
