I have downloaded and read the Office Policies and Informed Consent, the Financial Agreement, and the HIPAA Notice documents available on http://www.drkleinpsychology.com and I agree and consent to all policies. I have had the opportunity to ask questions about all policies. I also consent that “Reliable MH Billing” company will bill my insurance and/or that I will receive either post or email billing, at the addresses provided above, containing my statements or other relevant information.

CONFIDENTIAL

Dr Klein Psychological Services, Inc, 990 Highland Dr, 105A, Solana Beach CA 92075 Phone: 858-436-7264, Fax: 858-925-8035, drklein@mdofficemail.com