Client acknowledgement:
By signing below, I contract with Dr. Ritter for counseling services. I agree to pay that portion of each session’s fee for which I am responsible at the time the service is rendered. I further agree that I will notify the office at least 24 hours in advance if I will be unable to make any scheduled appointment. I understand that I may be charged a fee for failing to provide such notice. This agreement for services will remain in effect for 180 days after my last office visit; it may be revoked or rescinded at any time.
I have read, understand, and agree with the Contract for Services.
I have read and understand the Notice of Privacy Practices.
In addition to the above agreements, my signature below authorizes Dr. Ritter to share with medical professionals whatever is necessary to coordinate services, to file insurance on my behalf, and to provide whatever information the insurance company requires to process the claim.
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