Information Forms

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NOTICE OF PAYMENT POLICY AND PROCEDURES

CREDIT CARD AUTHORIZATION FORM

CREDIT CARD REVOCATION FORM

INFORMATIONAL FORMS

INFORMED CONSENT REGARDING ELECTRONIC COMMUNICATION

GUIDELINES FOR INCLEMENT OR WINTER WEATHER

PROTECTED HEALTH INFORMATION AND HIPAA - YOUR RIGHTS AND OUR RESPONSIBILITIES

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule provides consumers with important privacy rights and protections with respect to their health information, including  important controls over how their health information is used and disclosed by health plans and health care providers.  Ensuring strong privacy protections is critical to maintaining individuals’ trust in their health care providers and willingness to obtain needed health care services, and these protections are especially important where very sensitive information is concerned, such as mental health information.

For more information about your rights and our responsibilities, visit the U.S. Department of Health and Human Services - HIPAA Privacy Rule and Information Pertaining to Mental Health 

GIL INSTITUTE NOTICE OF PRIVACY PRACTICES RELATED TO PROTECTED HEALTH INFORMATION (PHI)

CLIENT ACKNOWLEDGEMENT OF RECEIPT AND REVIEW OF PRIVACY RIGHTS