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The Confident Clinician Cooperative serves to assist practice owners and support staff in credentialing so they can work with and bill third party payers. This form is intended to assist with preparation for your mentorship session. The information collected here assists the CCC with customizing your mentoring experience.
To get started, replace this text with your own.
With purchase of mentorship services, I understand that these will be used in a timely manner. Emerald and Topaz Star sessions (individual or group a la carte for 60 minutes) are allotted 30 days to schedule and complete the session. Sapphire Star (individual or group bundled 5 hour-long sessions) purchases are allotted 180 days to schedule and complete the sessions. Diamond Star Clinician monthly consult package must be completed within a year. Please refer to www.confidentclinician.com for further details of gem-stone packages.
I agree to the terms above and understand that by typing my name, this is acting as an Electronic Signature Acknowledgement and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically.
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