My signature acknowledges that I have been provided the professional qualifications of my provider, a listing of actions that constitute unprofessional conduct according to Vermont statutes, the methods for making a consumer inquiry or filing a complaint with the Office of Regulation, and if this disclosure is for a psychiatric or medical provider, the prescription policy for that provider
My signature below also acknowledges that I have received the “Notice of Mental Health Policies and Practices to Protect the Privacy of Your Health Information” from Networks, Inc. Any questions that I’ve had regarding this information have been asked and answered by my provider.