Mental Health Care Forms

Click to download forms

Patient Consent Agreement




  • Date Format: MM slash DD slash YYYY
  • Patient Information:

  • Date Format: MM slash DD slash YYYY
  • Insurance Information:

  • Responsible Party:

  • Consent for Services and Acknowledgement of Receipt of Policies:

    I request the above services of Carol Gibbs, MD and/or clinicians supervised by Carol Gibbs, MD as Senior Health and Education Partners, PLLC (SHAE) and request that payment authorized insurance (including Medicare) benefits be made on my behalf to SHAE for these services. I authorize any holder of medical information about me to release to my insurance company or to the Centers for Medicare and Medicaid Services and its agents and information needed to determine these benefits or the benefits payable to /for related services, including but not exclusive of a clinical diagnoses, treatment plans and summaries and/or copies of the entire record. By signing this agreement, you agree that SHAE Partners can provide the requested information to your carrier. I understand that my insurance company may assign a portion of the bill as patient liability. I understand that my records will be kept on file at the facility where services are provided and securely in an Electronic Medical Record. I authorize the release of information to my Attending Physician and /or facility as applicable. My responsible party (financial agent) may be informed that I am receiving services for billing purposes unless I request otherwise. I authorize SHAE Partners to seek emergency medical care on my behalf if deemed necessary. I have received SHAE’s Notice of Privacy Practices and Client Rights and Grievance Policies. I acknowledge that I have the right to refuse treatment as described in the statute without threat or termination of services except as outlined in G.S. 122-C-57(d); 10A NCAC 27D . 0303 (c). This consent for treatment may be withdrawn at any time.

  • Medication Consent

    The risks, side effects, benefits, and possible drug-drug interactions of possible prescribed medication(s), as well as those of all medications currently prescribed by this office for this patient, are understood by the patient or his/her legal guardian, including, where applicable, their risks in pregnancy, in the elderly, and other pertinent risk factors, such as any FDA black box warnings. Alternatives to medications, such as therapy and non-medication strategies, are understood. The patient or his/her legal guardian are indicating understanding and have given informed consent for medication(s) and or therapies to be prescribed for their intended use as part of the treatment process. Some of the major relevant side-effects reviewed, listed below, by class, include:

    Donepezil, galantamine, and rivastigmine improve the function of nerve cells in the brain and are used to treat dementia. People with dementia usually have lower levels of the chemical acetyl-choline, which is important for the processes of memory, thinking, and reasoning. Possible side effects include nausea, vomiting, loss of appe-tite/weight loss, diarrhea, weakness, dizziness, drowsiness, and shakiness (tremor) may occur as your body adjusts to the drug. These effects usually occur when you start the medication or increase the dose and then lessen.

    Antidepressant/Anxiolytic/Sedative-Hypnotic/Alpha-1 Agonist
If patient was or is being prescribed one of these classes of medications for his/her condition(s), possible side effects and risks include the risk of nausea, sedation, headaches, falls, insomnia, agitation, and possible suicidal or homicidal ideations or gestures, especially in children and adolescents, as well as other relevant risks and side effects that might pose a risk or danger to the patient, including off-label use, if applicable.

    Antipsychotic/Mood Stabilizers/Anti-Epileptics
If patient was or is being prescribed one of these classes of medications, possible side effects and risks include the risk of side effects such as blood dyscrasias, weight gain, diabetes, insulin resistance, endocrine abnormalities, tardive dyskinesia, dystonic reactions, EPS, NMS, renal and liver impairment, sedation, nausea, insomnia, agitation, and possible suicidal or homicidal ideations, especially in children and adolescents, risk of sudden death in the elderly, as well as other relevant risks or side effects that might pose a risk or danger to the patient, including off-label use, if applicable, and the possible requirement for routine lab/blood monitoring.

    The patient or his/her parent or legal guardian may ask any additional questions about, and discuss,
    these and other possible risks, side-effects, and off-label uses by calling (919) 457-1517.

  • Verbal Consent (if signature cannot be obtained):

  • :
  • (must have 2 witnesses for verbal consent)
  • Patient consents to treatment but was unable to sign acknowledgement forms due to
    (be specific-i.e., blind, has dementia, has legal guardian):

  • When complete, please fax to (919) 363-7697 along with patient’s demographics and insurance.


    SHAE Partners


    During the course of providing services and care to you, SHAE Partners gathers, creates, and retains certain personal information about you that identifies who you are and relates to your past, present, or future physical or mental condition, the provision of health care to you, and payment for your health care services. This personal information is charac-terized as your “protected health information.” This Notice of Privacy Practices describes how SHAE Partners maintains the confidentiality of your protected health information, and informs you about the possible uses and disclosures of such information. It also informs you about your rights with respect to your protected health information.


    SHAE Partners is required by federal and state law to maintain the privacy of your pro-tected health information. SHAE Partners is also required by law to provide you with this Notice of Privacy Practices that describes SHAE Partners’s legal duties and privacy practices with respect to your protected health information. SHAE Partners will abide by the terms of this Notice of Privacy Practices. SHAE Partners reserves the right to change this or any future Notice of Privacy Practices and to make the new notice provisions ef-fective for all protected health information that it maintains, including protected health information already in its possession. If SHAE Partners changes its Notice of Privacy Practices, it will personally deliver or mail a revised notice to you at your current address.


    SHAE Partners will require a written authorization from you before it uses or discloses your protected health information, unless a particular use or disclosure is expressly per-mitted or required by law without your authorization. SHAE Partners has prepared an authorization form for you to use that authorizes SHAE Partners to use or disclose your protected health information for the purposes set forth in the form. You are not required to sign the form as a condition to obtaining treatment or having your care paid for. If you sign an authorization, you may revoke it at any time by written notice. SHAE Partners then will not use or disclose your protected health information, except where it has al-ready relied on your authorization.


    1. Permissive Disclosures

    SHAE Partners may, in its discretion, use or disclose your protected health with-out your written authorization in the following circumstances:

    a. Your Care and Treatment

    SHAE Partners may use or disclose your protected health information to provide you with or assist in your treatment, care and services. For exam-ple, SHAE Partners may disclose your health information to health care providers who are involved in your care to assist them in your diagnosis and treatment, as necessary. SHAE Partners may also disclose your pro-tected health information to individuals who will be involved in your care if you leave the SHAE Partners.

    b. Billing and Payment

    i. Medicare, Medicaid and Other Public or Private Health Insurers – SHAE Partners may use or disclose your protected health infor-mation to public or private health insurers (including medical in-surance carriers, HMOs, Medicare, and Medicaid) in order to bill and receive payment for your treatment and services that you re-ceive at the facility. The information on or accompanying a bill may include information that identifies you, as well as your diag-nosis, procedures, and supplies used. SHAE Partners will electron-ically transmit required health information according to Federal and State requirements.

    ii.Health Care Providers – SHAE Partners may also disclose your pro-tected health information to health care providers in order to allow them to determine if they are owed any reimbursement for care that they have furnished to you and, if so, how much is owed.

    c. Health Care Operations

    SHAE Partners may use your protected health information for health care operations at SHAE Partners. These uses and disclosures are necessary to manage the facility and to monitor our quality of services and care. For example, we may use your protected health information to review our ser-vices and to evaluate the performance of our staff in caring for you.

    d. Licensing and Accreditation

    SHAE Partners may disclose your protected health information to any government or private agency, such as to the North Carolina Department of Health Services and the North Carolina Department of Social Services, responsible for licensing or accrediting SHAE Partners so that the agency can carry out its oversight activities. These oversight activities include audits; civil, administrative, or criminal investigations; inspections; licen-sure or disciplinary actions; civil, administrative, or criminal proceedings or actions; or other activities necessary for appropriate oversight.

    e. SHAE Partners’s Special Directory

    SHAE Partners maintains a Special Directory of patients to allow staff to provide certain basic information to members of the clergy who serve SHAE Partners or to other persons who ask for patients by name. Unless you notify SHAE Partners that you object, it will include certain limited information about you, such as your name, your location in SHAE Part-ners, your general condition, and your religious affiliation in its Special Directory.

    f. Individuals Involved in Your Care or Payment for Your Care

    Unless you specifically object, SHAE Partners may disclose to a family member, other relative, a close personal friend, or to any other person identified by you, all protected health information directly relevant to such person’s involvement with your care or directly relevant to payment relat-ed to your care. SHAE Partners may also disclose your protected health information to these same individuals to assist in notifying them of your location, general condition, or death.

    g. Disaster Relief

    SHAE Partners may disclose your protected health information to a public or private entity authorized to assist in disaster relief efforts.

    h. Business Associates

    SHAE Partners may contract with certain individuals or entities to provide services on its behalf. Examples include data processing, quality assur-ance, legal, or accounting services. SHAE Partners may disclose your protected health information to a business associate, as necessary, to allow the business associate to perform its functions on the SHAE Partners’s be-half. SHAE Partners will have a contract with its business associates that obligate the business associates to maintain the confidentiality of your pro-tected health information.

    i. Hospital Peer Review

    SHAE Partners may disclose your protected health information to hospital medical staffs to aid in the credentialing of applicants and in the peer re-view of members.

    j. Organ Procurement

    SHAE Partners may disclose your protected health information following your death to an organ procurement agency or tissue bank in order to aid in using your organs or tissues in transplantation.

    k. Appointment Reminders

    SHAE Partners may use or disclose your protected health information to remind you about appointments.

    l. Treatment Alternatives or Health-Related Benefits and Services

    SHAE Partners may use or disclose your protected health information to inform you about treatment alternatives or health-related benefits and services that may be of interest to you.

    m. Members of Workforce

    It is SHAE Partners’s policy to allow members of its workforce to share patients’ protected health information with one another to the extent necessary to permit them to perform their legitimate functions on SHAE Partners’s behalf. At the same time, SHAE Partners will work with and train its workforce members to ensure that there are no unnecessary or extraneous communications that will violate the rights of its patients to have the confidentiality of their protected health information maintained.

    n. Veterans

    SHAE Partners may use and disclose to components of the Department of Veterans Affairs medical information about you to determine whether you are eligible for certain benefits.

    o. Workers’ Compensation

    SHAE Partners may use or disclose your protected health information to comply with laws relating to workers’ compensation or similar programs.

    2.Mandatory Disclosures

    SHAE Partners will disclose protected health information to outside persons or entities without your written authorization as required by law in the following cir-cumstances:

    a. Court Order; Order of Administrative Tribunal

    SHAE Partners will disclose protected health information in accordance with an order of a court or of an administrative tribunal of a government agency.

    b. Subpoena

    SHAE Partners will disclose protected health information in accordance with a valid subpoena issued by a party to adjudication before a court, an administrative tribunal, or a private arbitrator. Reasonable efforts will be made to notify you of the subpoena, or of efforts to obtain an order or agreement protecting your protected health information.

    c. Law Enforcement Agencies

    SHAE Partners will disclose protected health information to law enforce-ment agencies in accordance with a search warrant, a court order or court-ordered subpoena, or an investigative subpoena or summons.

    d. Coroner

    SHAE Partners will disclose protected health information to a coroner where the coroner requests the information to identify a decedent; to noti-fy next of kin; or to investigate deaths that may involve public health con-cerns, suspicious circumstances, elder abuse, or organ or tissue donation.

    e. Elder Abuse Reporting

    SHAE Partners will disclose protected health information about a patient who is suspected to be the victim of elder abuse to the extent necessary to complete any oral or written report mandated by law. Under certain cir-cumstances, SHAE Partners may disclose further protected health infor-mation about the patient to aid the investigating agency in performing its duties. SHAE Partners will promptly inform the patient about any disclo-sure unless SHAE Partners believes that informing the patient would place the patient in danger of serious harm, or would be informing the patients personal representative, whom the Provider believes to be responsible for the abuse, and believes that informing such person would not be in the pa-tient’s best interest.

    f. National Security and Intelligence Activities, Protected Services for the Patient and Others

    SHAE Partners will disclose protected health information about a patient to authorized federal officials conducting national security and intelligence activities or as needed to provide protection to the Patient of the United States, certain other persons or foreign heads of states, or to conduct cer-tain special investigations.

    g. Other Disclosures Required by Law

    SHAE Partners will disclose protected health information about a patient when otherwise required by law.


    You have the following rights with respect to your protected health information. To ex-ercise these rights, contact SHAE Partners at the following address: SHAE Partners, 5306 NC Hwy 55, Suite 105, Durham, NC 27713 Attention: Privacy Official.

    a. Right to Request Access

    You have the right to inspect and copy your protected health information main-tained by SHAE Partners. In certain limited circumstances, SHAE Partners may deny your request as permitted by law. However, you may be given an opportuni-ty to have such denial reviewed by an independent licensed health care profes-sional.

    b. Right to Request Amendment

    You have the right to request an amendment to your protected health information maintained by SHAE Partners. If your request for an amendment is denied, you will receive a written denial, including the reasons for such denial, and an oppor-tunity to submit a written statement disagreeing with the denial.

    c. Right to Request Restriction

    You have the right to request restrictions on the use and disclosure of your pro-tected health information for treatment, payment or health care operations, or providing notifications regarding your identity and status to persons inquiring about or involved in your care. SHAE Partners is not required to grant your re-quest, but if it does, it will comply with your request, except in an emergency sit-uation or until the restriction is terminated by you or SHAE Partners.

    d. Right to Request Confidential Communications

    You have the right to request that SHAE Partners communicate protected health information to the recipient by alternative means or at alternative locations.

    e. Right to an Accounting

    You have the right to receive an accounting of disclosures of your protected health information created and maintained by SHAE Partners over the six years prior to the date of your request or for a lesser period. SHAE Partners is not re-quired to provide an accounting of the following disclosures:
    •To carry out treatment, payment, and health care operations;
    •To respond to your requests for access to protected health information;
    •To include your information in the SHAE Partners’s Special Directory;
    •To aid in the identification or care of a patient; or
    •To any recipient prior to April 14, 2003 or for protected health information cre-ated more than six years before the date of your request for an accounting.

    f. Right to Receive a Copy of the Notice of Privacy Practices

    You have the right to request and receive a copy of SHAE Partners’s Notice of Privacy Practices for Protected Health Information in written or electronic form.


    If you believe that your privacy rights have been violated, you may file a complaint with SHAE Partners at the following address: 5306 NC Hwy 55, Suite 105, Durham, NC 27713. Attention: Administrator.

    SHAE Partners will not retaliate against you if you file a complaint.

    The effective date of this Notice of Privacy Practices is October 15, 2014


    Each client has the right to treatment, including access to medical care and habilitation, regard-less of age or degree of disability. G.S. 122C-51. Each client has the right to an individualized treatment plan. Each client has the right to be free from unnecessary or excessive medication. Medication shall not be used for punishment, discipline, or staff convenience. SHAE Partners Physicians, Physician Assistants, and Nurse Practitioners will prescribe medications in accordance with accepted medical standards and will document such prescriptions and such medications in the client's record. Unless treatment is under court order, each client or legally responsible person, or health care agent named pursuant to a valid health care power of attorney, has the right to consent to or refuse treatment offered by SHAE Partners. Consent may be withdrawn at any time by the person who gave consent. If treatment is refused, the clinician should determine whether treatment in some other modality is possible. If all appropriate treatment modalities are refused, the client may be discharged from services unless treatment is court-ordered.

    SHAE Partners employees do not inflict or recommend corporal punishment of any client. SHAE Partners employees do not order or use physical restraints, seclusion, or isolation. Each client shall be free from unwarranted invasion of privacy. Generally, SHAE Partners staff does not conduct searches of the client or his/her living area or seizures of property, but SHAE Partners may recommend such searches to be conducted in accordance with facility policies.

    SHAE Partners will provide each client/legally responsible person seen under a Mental Health Contract with a written summary of client rights. Clients shall be informed of their rights to contacts Disability Rights North Carolina (DRNC), the statewide agency designated under State law to protect and advocate for the rights of persons with disabilities. Explanation shall be in a manner consistent with the client's or legally responsible person's level of comprehen-sion.


    A grievance is defined by Senior Health and Educations Partners, PLLC (SHAE) as: Client complaint or expression of dissatisfaction regarding service delivery, or any expression of dissatisfaction by the service provider.

    II. Procedures

    a. Client or service provider expresses dissatisfaction verbally or in writing.

    b. SHAE staff member will attempt to resolve situation with the client or service provider.

    c. If this is not possible, then the SHAE staff who receives complaint shall notify Terrence Laster, Quality Assurance Coordinator, who will document the complaint in the Grievance Log. The Grievance Log shall include the following information:

    Client ID# (not name)
    Nature of complaint
    Identification of those involved
    Date complaint received and by whom
    Summary of follow-up activities
    Date grievance referred to QA Committee, if necessary
    Date of resolution

    d. The Quality Assurance Coordinator will be responsible for collecting relevant information about the grievance, for taking action to resolve the grievance and for documenting all progress.

    e. The Quality Assurance Coordinator will attempt to resolve the complaint between the parties involved. If no satisfaction results, and disenrollment or termination of a contract might be appropriate, the Quality Assurance coordinator will present the situation to the Quality Assurance Committee for a decision.

    f. Thirty days after expressing grievance, clients or service providers will receive in writing all grievance facts and decisions.

    If this procedure is not clear, or you have any questions, please call Agency Director at (919) 457-1517

Facility Partnership Agreement


    This facility agreement (the “Agreement”) is made by and between Senior Health and Education Partners, PLLC, a North Carolina professional limited liability company (hereafter referred to “SHAE”) and the aforementioned facility.

  • Services to be provided by SHAE under this Agreement (collectively, hereto after referred to as the “Services”):

    Mental Health ..................................

    The Agreement is made effective as the date indicated on the signature page hereto by and between SHAE and the Facility (the “Effective Date”).


    A. SHEA is a provider of medical care services including, but not limited to, psychiatry (including Psych Medication Management (collectively the Services) and

    B. Facility is a licensed long term care facility and desires to engage SHEA to provide Services at the Facility under the terms and subject to the conditions of this agreement and SHEA desires to accept such engagement. NOW THEREFORE, in consideration of the mutual promises and covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereto agree as follows:

    1. Term and Termination. The term of this Agreement shall commence on the “Effective Date” and continue in full force and effect until either party gives at least thirty (30) days written notice to the other party of its intention to terminate the Agreement.

    2. Responsibilities of SHEA.
    a. SHEA, through its Providers (defined below), shall provide Services in a professional and efficient manner consistent with the customary delivery of Mental Health services in the State of North Carolina. SHEA shall use reasonable efforts to provide sufficient numbers of Providers to meet the Facility’s coverage requirements and that such Providers will perform their obligations in accordance with standards of care rendered by behavioral health professionals practicing in the state in which the facility is located. All mental health professionals, including physicians, nurse practitioners, physician assistants, psychologists, and social workers (the Providers”) assigned to the Facility by SHEA to provide “Services” have and maintain in good standing all federal, state and local licenses, certifications, registrations, and permits which are required to provide the “ Services” according to the laws and regulations of the State of North Carolina. Any non-physician Provider shall be adequately supervised by a SHEA physician.

    b. SHEA shall provide the “Services” only at the request of the patient or authorized Facility personnel. Evaluations and assessments will be seen within a reasonable time after referral is made. SHEA shall use commercially reasonable efforts to consult new patients within 72 hours of a request.

    c. SHEA shall provide timely communication with the Facility’s intake division, billing team, and scheduling regarding SHEA caseload for each Provider at the Facility.

    d. SHEA shall provide detailed medical records with documentation of visits to the facility within 24 hours of each patient encounter, copies of which SHEA will also keep.

    e. SHEA agrees to assist the “Facility”, at its request, in complying with managed care and regulatory guidelines and requirements.

    3. Responsibilities of Facility.
    Facility shall be responsible for:

    a. Designating a Facility staff person to liaison between the Facility and SHEA;

    b. Complying with generally accepted procedures and standards in making referrals to SHEA, including, without limitation, provision of the following information for each referred patient: (i) name and/or responsible party’s name and contact information; (ii) name and contact information for referring person and attending physician; (iii) medical history and other appropriate medical information available to Facility; (iv) information to facilitate and enable SHEA to obtain appropriate consent for Services; (v) information to facilitate and enable SHEA’s billing of payers for Services;

    c. Providing a consultation room for private evaluations of patients by the SHEA Providers;

    d. Providing timely communication in circumstances involving a patient’s emergent medical condition.

    4. Billing. SHEA’s sole compensation for Services rendered directly to patients shall be for fees received by SHEA from such patients or third parties for such Services, and SHEA shall not bill the Facility for, nor be entitled to compensation from the Facility for time spent by SHEA or any of its Providers in the rendition of services to patients.

    5. Miscellaneous Provisions.

    a. Independent Contactor Status. No relationship of employer and employee is created by this Agreement, it being understood that SHEA and all its Providers shall act as independent contractors with respect to the Facility, not being subject to the direction and control of the Facility in the daily provision of contract services. The Facility shall neither have nor exercise any control or direction over the methods by which the SHEA shall perform the Services.

    b. Medical Records. Facility represents that it maintains medical records documenting the treatment provided by Facility staff and independent contractors and that it requires inclusion of SHEA’s clinical records in the “Facility’s” medical records in compliance with applicable law and/or to assure the continuity, coordination and consistency of the care provided by Facility staff and independent contractors. Facility agrees to safeguard the confidentiality of its medical records including all patient information provided by SHEA, and to comply with all applicable state and federal laws governing the confidentiality and security of such records. Facility shall not use or disclose patient information provided by SHEA except as permitted by law.

    c. HIPAA Compliance. The parties shall preserve the confidentiality of patient records to the extent required by law, and shall use protected health information contained in such records only to the extent permitted by applicable law. SHEA acknowledges that it meets the definition of a "business associate" and Facility acknowledges that it meets the definition of a "covered entity" as set forth in HIPAA.

    d. Non-Solicitation of SHEA Providers. During the Term of this Agreement and for a period of one (1) year following the last day of this Agreement, Facility shall refrain from (ii) directly or indirectly hiring, retaining, engaging soliciting or assisting others in hiring , retaining, engaging , or soliciting for employment or work in any capacity any SHEA Provider involved in providing services contemplated by this Agreement; and (ii) directly or indirectly soliciting , encouraging, inducing or assisting others in soliciting, encouraging or inducing any Provider of SHEA involved in providing services contemplated by this Agreement to terminate his or her employment with SHEA. The parties acknowledge that a breach of subsection 5. (D) by the Facility would result in irreparable damage to SHEA , and , without limiting other remedies which may exist for breach of subsection 5. (D), the parties agree that subsection 5. (d) may be enforced by temporary restraining order, temporary injunction and permanent injunction restraining violation hereof, pending or following a trial on the merits. The parties herby waive the claim or defense that an adequate remedy at law for such breach exists or that irreparable injury will not occur.

    e. Indemnification. To the extent not covered by a policy of insurance covering the Indemnified Party (as defined below), each party (the Indemnifying Party) shall indemnify and hold harmless the other party and their respective employees, agents, representatives, successors and assigns(collectively, the “Indemnified Party”) from any and all claims, suits, actions, liabilities, damages, and costs of any kind, including reasonable attorneys’ fees, arising from or in connection with any acts or omissions of the Indemnifying Party, or any of its employees, agents, officers, directors, shareholders, managers, members or representatives.

    f. Insurance. SHAE Partners shall maintain professional liability insurance on a continuing basis for SHAE and each Provider providing “Services” under this Agreement, with per occurrence limits of liability not less than $1,000,000 per occurrence and $3,000,000 aggregate coverage.

    g. Confidentiality. Both parties understand that this Agreement creates a relationship of trust and respect to any information of the confidential or secret nature regarding their respective businesses including, but not necessarily limited to, business methods and practices, business forms, employee information and customer lists ( “Proprietary Information”) that if disclosed to others may be harmful to their businesses. Therefore, at all times during the Term of this agreement and after its termination each party will keep and hold all such Proprietary Information of the other party in strict confidence and trust and will not disclose such Proprietary Information without the prior written consent of the other party.

    h. Assignment. Neither party may assign or transfer this Agreement or any part hereof without prior written consent from the other party. There are no third party beneficiaries of or to this Agreement.

    i. Governing Law: Severability. This Agreement shall be governed by and construed in accordance with the laws of the State of North Carolina without regard to or application of choice of law rules or principles. In the event that a court finds any provision of this Agreement invalid or unenforceable, the remainder of this Agreement shall remain in full force and effect.

    j. Entire Agreement. This Agreement constitutes the entire Agreement between the parties and all prior agreements, negotiations or representations regarding the subject matter of this Agreement are of no force or effect unless expressly set forth herein. This Agreement may be amended at any time by mutual agreement of the parties, but such amendment shall not be valid unless it is in writing and signed by both parties.

    k. Exclusive Contract. Facility desires to ensure proper, orderly and efficient delivery of Services to its residents. Facility has determined that an exclusive arrangement is the best means by which these goals can be achieved. Accordingly, Facility agrees that during the term of this Agreement and for so long as SHAE is not in breach of this Agreement, SHAE Partners shall be the exclusive provider of Services at the Facility. The exclusivity provided under this subsection k. shall not apply to any service not provided by SHAE Partners to Facility under this Agreement.

  • Date Format: MM slash DD slash YYYY
  • Senior Health and Education Partners, PLLC, a North Carolina professional limited liability company
  • Date Format: MM slash DD slash YYYY
  • Dr. Carol Gibbs, Managing Partner
  • Date Format: MM slash DD slash YYYY