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Informed Consent HIPAA EL.doc 2026

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The document is an Informed Consent Form and HIPAA guidelines for counseling services provided by Erin Leyba, LCSW, PhD. It outlines the therapist's qualifications, confidentiality policies, emergency procedures, financial responsibilities, and client rights. The form emphasizes the importance of informed consent in treatment and includes sections for clients to authorize communication with other healthcare providers.

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Click ‘Get Form’ to open the Informed Consent HIPAA EL.doc in the editor.
Begin by reviewing the introductory section, which outlines the purpose of the document and introduces Erin Leyba, LCSW, PhD. This will help you understand what to expect during your counseling sessions.
Fill out the confidentiality and privacy practices section. Ensure you read through each point carefully, as it details how your information will be handled.
In the financial/insurance issues section, indicate your payment preference. You can choose to pay out-of-pocket or utilize insurance options. Make sure to provide any necessary details for billing.
Complete the coordination of treatment section if you consent to communication with other healthcare providers. Fill in your physician's name and contact information as required.
Sign and date at the designated areas throughout the document where indicated. This confirms your understanding and agreement with all terms outlined.

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