PATIENT REGISTRATION

-I understand that information I give my provider will be kept confidential, but my provider is required by law to report evidence of child abuse.

-I understand that I am responsible for my bill.

I understand that I am responsible for payment for any and all missed session for which I do not notify the doctor of the cancellation at least 24 hours in advanced. These are the fees for missed appointment:
- Nurse Practitioner-$60
- Therapist- $75
- Doctor-$80

I authorize release of information to my credit card company in case I dispute charges.
Signature of Patient / Guardian

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PATIENT ACKNOWLEDGEMENT

I hereby acknowledge that I have received a copy of the Notice of Privacy Practices of Private Mental Health Group, LLC.
Signature of Patient (or authorized representative)

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Patient Name (print)
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