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Maia S. Deubert Psy. D. Licensed Clinical Psychologist 1489 CHAIN BRIDGE ROAD SUITE 203 MCLEAN VA 22101 703. Signature of adolescent Date RESPONSIBLE FOR THE PRACTICE OF MAIA S. DEUBERT PSY. D. AND THAT EACH CLINICIAN HAS HIS/HER INDIVIDUAL PRIVATE PRACTICE THAT IS SEPARATE FROM THE GROUP NAME. PATIENT NAME BILLING ADDRESS FEES PER VISIT SPECIAL PAY ARRANGEMENTS I hereby authorize Maia S. Deubert Psy. You may revoke all such authorizations of PHI or Psychotherapy Notes at any time provided...
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