CHAMPION PSYCHOLOGICAL SERVICES, LLC
P.O. Box 2623 Mercerville, NJ 08619
Date of Birth:
I have received a copy of the “HIPAA Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information”. The Notice provides in detail the uses and disclosures of my “Protected Health Information” that may be made by my psychologist, my individual rights, how I may exercise these rights, and my psychologist’s legal duties with respect to my information.
I consent to release of “Protected Health Information” for the purpose of treatment, payment, and healthcare operations. I understand that any other use of my “Protected Health Information” will require my specific authorization.
Patient Name Printed & Date :
Patient Signature & Date :
Gaurdian Name Printed & Date :
Gaurdian Signature & Date :