~ Signature Page For All Forms ~

By using this form below, you understand that your submission may not be a secure and confidential form of communication.
If you wish to assure your confidentiality, rather than filling out and submitting this form, you can print and FAX the PDF form you received to: 802-727-4634.
 
Informed Consent, Patient Bill ‘o Rights, HIPAA, CMS-1500
 
I/we have read, understand and agree to the information and policies described in the Informed Consent Form.
 
My signature acknowledges that I have been given the professional qualifications and experience of David Levingston, a listing of actions that constitute unprofessional conduct according to Vermont statutes, and the method for making a consumer inquiry or filing a complaint with the Office of Professional Regulation.
 
This information was given to me no later than my third office visit.
 
I/we have read, understand and agree to the cancellation policy (does not apply to Medicaid).
 
I/we understand that if I/we miss a scheduled session and I/we don’t provide at least 24 hours’ notice, or if the absence is not due to an illness or emergency, I/we agree to pay $60 (plus $3 service fee if paying by card) for the missed session.
 
I/we acknowledge receipt of the Patient Bill of Rights.
 
I/we acknowledge receipt of the HIPAA and Notice of Privacy Practices, which describes how medical information about you may be used and disclosed and how you can get access to this information.
 
I give permission to be contacted by David Levingston in writing if necessary,
and/or to be sent a feedback survey sometime after therapy has ended.
 
For Managed Care Plans (the CMS-1500 form):
 
I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment.
 
I authorize payment of medical benefits to the undersigned physician or supplier for services described.
 
Please fill all fields below to indicate your agreement: