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Treatment Forms

Treatment Agreement and Consent

For the purposes of this document, “the patient” refers to the person(s) receiving services at Hoffman Psychiatric Services and “Dr. Hoffman” refers to Dr. Sigalit Hoffman providing said services.

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Financial Policy Agreement

You are responsible for any and all charges incurred for rendered services withHoffman Psychiatric Services including any monies due and owing under your health insurance plan (i.e., copayments and unmet deductibles) or other third-party payor (i.e., Employee Assistance Programs [EAPs]).

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Consent for Telehealth

I understand that Hoffman Psychiatric Services providers may provide me with services via telehealth.

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Authorization to Release Medical Information

I authorize the named clinician to share my mental health records with the designated party for the stated purpose(s). I understand that this authorization will expire once treatment ends or if I request its removal.

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