Provider Agreement Provider Agreement Policy and Procedure Manual HIPAA Privacy Rules Code of Ethics I have read the Policy and Procedure Manual for Transformations hope for today’s families LLC and agree to comply with all the manual procedures, the HIPAA privacy rules, the AAMFT code of ethics and the code of ethics for my profession. I understand that I will be notified when policies are added or updated and that it is again my responsibility to familiarize myself and comply with the policy update. Key Agreement I agree to return to the agency any agency keys in my possession upon termination of my contract or employment with Transformations. Website and Promotional Materials Release I give Transformations hope for today’s families LLC permission to use my professional information and photo(s) on the agency website, social media, and other promotional material. I understand that I can edit or modify this release and the following information at any time by notifying the office. Transportation Agreement I have read Transformations’ Policy and Procedures regarding Distracted Driving and Transporting of Clients and agree to comply with these policies and accept responsibility to review and comply with future updates. I understand that if I chose to transport clients, that I am accepting responsibility and liability for the safety and transportation of my clients. I agree to maintain my vehicle for best safety and performance. I agree to maintain automobile insurance that states I am covered for business purposes and to supply Transformations with a certificate of automobile insurance that states coverage for business purposes. I understand that I must keep this policy active and provide Transformations with ongoing proof of coverage or notify Transformations in writing seven days prior to terminating. I understand that if I were to transport clients without first providing Transformations with proof of auto insurance for business purposes, that I will be in violation of my contract with Transformations and subject to termination of the contract. I have read and agree to the above policy and procedures.* Yes Signature of Provider*Name of Person Signing*Email Address* Date* MM slash DD slash YYYY
