2021 Client Update and HIPAA Acceptance Form - Bevill and Associates Behavioral Health

2021 Client Information Update and HIPAA Acceptance Form

Name *

First

Last

Has your contact information changed in the last 12 months? If so please update your information below: *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Has your Credit Card / Debit Card/ HSA Card changed in the last 12 months? If so please update your information below: *

Credit Card Number

Expiration Date

CV Code

Has your insurancechanged in the last 12 months? If so please update your information below: *

Primary Policy Holder Name

First

Last

Contract Number

Group Number

Date of Birth of Client / Patient

PRIVACY POLICY I acknowledge having been offered Bevill and Associates "Notice of Privacy Policies"and their "Client Rights Statement". My rights include the right to see and copy my record, to limit disclosure of my health information, and to request an amendment to my record.These are explained in the Policy. My right to make a complaint and file a grievance has also been explained. I understand that I may revoke in writing my consent for release of my health care information except to the extent Bevill and Associates has already made disclosure with my prior consent. Privacy Policy- https://bevillandassociates.com/privacy/ CONSENT FOR TREATMENT I hereby consent to the treatment provided by Bevill and Associates and its employees or designees. I authorize the services deemed necessary or advisable by my caregivers to address my needs. PLEASE E-SIGN BELOW TO INDICATE THAT YOU HAVE READ AND UNDERSTAND THE ABOVE NOTIFICATIONS AND THAT YOU ARE CONSENTING TO RECEIVE TREATMENT BY Bevill and Associates LLC. Type your First and Last name (E-signature) *

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