Notice of Richard E Hicks, PhD joining

HRC Behavioral Health Psychiatry, PA

4201 Lake Boone Trail, Suite 201, Raleigh, NC 27607, (919) 785-0384

(Effective 07/15/2013)

It is with great pleasure that I am writing to let you know that effective 07/15/2013; I will be joining HRC Behavioral Health and Psychiatry, a group practice with offices in Raleigh and Chapel Hill-Durham.

Why am I joining HRC?

--HRC will offer my clients and me convenient access to a great team of clinicians. HRC is one of the oldest and largest clinical practice groups in the southeast - a comprehensive, multi-disciplinary group practice of psychologists, psychiatrists, social workers, and marriage and family therapists offering quality mental health services in both Raleigh and Chapel Hill-Durham.

--HRC will offer my clients and me convenient access to an experienced team of administrative support staff, who will handle the business side of my practice (e.g. insurance billing, client accounts, electronic health records, etc.). This will allow me to focus primarily on client care - more time for clients and opportunities to provide a wider array of services.

-- HRC will provide my clients and me the ability to meet in several convenient locations – my current office on Oberlin Rd; an office near Rex Hospital in Raleigh; and an office at the Europa Center, just off I-40 between Chapel Hill and Raleigh.

How might this change our work together?

-- Our work together should not change very much. Our interactions and communication together will remain the same (e.g. scheduling; appointment hours; phone & email availability; etc).

-- We may meet in a new office location, depending on the day, the time, and your preference of meeting location. My “main” office will move to 4201 Lake Boone Trail, approximately 7 minutes (3.5 miles) away from my Oberlin Rd office.

-- There will be a few new forms to fill out, to make sure the HRC staff have what they need to file your insurance, keep track of billing, and take care of all that “paper work.”

Before you leave the office today, please sign this form and the REH/HRC Authorization form. Please also complete the other forms, either today or prior to our next appointment.

Notice of Richard E Hicks PhD joining HRC; Updated 07/02/2012

 Notice of Richard E Hicks, PhD joining HRC Behavioral Health & Psychiatry, PA

Notice of Richard E Hicks PhD joining HRC; Updated 07/02/2012

 REH/HRC Authorization Form - Transfer & Exchange of Health Information with HRC

Notice of Richard E Hicks PhD joining HRC; Updated 07/02/2012

 Patient Data Form

 HRC Authorization Form

 HRC Provider-Patient Services Agreement

 HRC Privacy Notice

 HRC Missed Appointment Agreement

Notice of Richard E Hicks PhD joining HRC; Updated 07/02/2012

Your signature below indicates that you have read this notice and received the forms listed above. Specifically, serves as an acknowledgement that you have received the notice of privacy (HIPPA) form described above and

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Patient’s Name (Please print) Signature of Patient & Date

______Personal Representative (Please print) Signature of Personal Representative & Date

______

Relationship of Personal Representative to Patient Witness (if applicable) & Date

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Responsible Party, if other than client (Please print) Signature of Responsible Party & Date

Notice of Richard E Hicks PhD joining HRC; Updated 07/02/2012