I (we) hereby give consent to Cognitive Hygiene to provide treatment for me (us) and/or for my minor child(ren) which may include but is not limited to various therapies, transportation, psychosocial, recreational activities, and/or medical intervention. The risks and benefits of treatment have been explained to me (us) and I understand that it is exempt from any liability.
I (we) also understand that clinical records may be reviewed by the Quality Assurance Committee and/or a clinical supervision to ensure quality of treatment for myself(our family). Information necessary to carry out treatment, payment and healthcare operations will be submitted to appropriate organization for accreditation, certification, or authorizations.
Additionally,if I (we) apply for all or part of my (our) treatment to be funded by various third parties other than Medicaid/Medicare, then I (we) understand and agree that information necessary to carry out treatment, payment, and health care operations will be submitted to those various third parties funding for my (our) treatment. Cognitive Hygiene, Client Grievance Procedures, Client Rights and Responsibilities and Notice of Privacy Practices have been explained to me and I have received my own copy. If Cognitive Hygiene Privacy Practices Should Change, I will be notified by receipt of the new Notice of Privacy Practices.
To provide treatment to minors Cognitive Hygiene is required to obtain consent for treatment from the minor’s legal guardian or custodian. By signing below, you are attesting that you are legally or custodial responsible for minors named below.