For Blue Cross Blue Shield Clients only: I understand that I may be seen by a Master’s level clinician seeking independent licensure at WBH. I have been informed that I have the option to wait to see an independently licensed clinician and I am choosing to be seen by a Master’s level clinician seeking independent licensure at WBH instead.
NOTICE OF PRIVACY PRACTICES
IBC's “Notice of Privacy Practices” is available to review below, and is also available at www.thewellbh.com. I am aware that I can also ask my clinician for a paper copy. I understand that I may ask questions about the information outlined in the Notice at any time in the future.
I give permission to WBH to contact me at the phone number(s) or email listed on this Client Registration Form. If I am not available, I authorize WBH to leave a message on my voicemail. My signature below indicates that I am aware that the “Electronic Communication Policy” is available for my review at www.thewellbh.com. I am aware that I can ask my clinician for a paper copy.