Patient Coordination of Care

COORDINATION OF CARE ACKNOWLEDGMENT BETWEEN PHYSICIAN AND
COUNSELOR 


1. I understand that I am receiving coordination of care services from Virginiann
Vigliotta and Dr. Kathleen Glover PLLC I agree to the following:
   a. I will provide V. Vigliotta PMHNP with accurate and complete information
about my health and treatment history.
   b. I will attend all scheduled counseling sessions and participate in my treatment
plan.
   c. I will follow the instructions of my counselor.
   d. I will keep my counselor informed of any changes in my health or treatment
needs.
   e. I understand that I have the right to:
      i. Ask questions about my care.
      ii. Refuse any treatment or service.
      iii. Get a second opinion.
      iv. File a complaint with V. Vigliotta PMHNP


I understand that my coordination of care services are confidential. V. Vigliotta PMHNP will
only share my information with others who need to know it in order to provide me with care.
I have read and understand this document, and I agree to the terms and conditions stated
above.

Coordinating Counselor

Coordinating Physician

Name
Name
First
Last
Patient