801-206-4200 chcs@clearhorizons.org

Services

Notice of Privacy Policies

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READ ONLY – Please read/review prior to signing the Client Information Form. Print and keep for your records.

Client Rights and Responsibilities

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READ ONLY – Please read/review prior to signing the Client Information Form. Print and keep for your records..

Client Information Form

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A Client Information form must be completed, signed, and returned prior to the first appointment.

 

For Adults (18 yrs. & older) with a scheduled appointment, complete the TOP section titled “PATIENTS 18 OR OLDER ONLY” and sign the back (Highlighted in BLUE)

For Children with a scheduled appointmentParents OR Foster Parents must complete the section titled “PARENT OR FOSTER FAMILY INFORMATION” and “CHILDREN INFORMATION” section. Sign the back as either (Legal Guardian/Parent – Highlighted in BLUE) or for Foster Parent (Highlighted in YELLOW)

 

NOTE: All Patients must complete the Payment Responsibility Section with correct insurance provider information or specify as CASH PAY. All cash pay patients will need to keep a valid credit card on file for payments.

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