(AAA/BC LOGO)

CLIENT AGREEMENT

(EXAMPLE)

I understand that the Texas Health Information, Counseling and Advocacy Program is a state-sponsored, non-profit program for persons needing assistance with their public and/or private benefits. Counseling services are intended to help me understand public and private benefits in an objective manner that supports my independent decisions. I understand that counseling services are provided by Certified Counselors, acting in good faith to provide information about public/private benefits to me, the client.

I understand that Certified Counselors are not permitted to render legal advice or other legal services which would be construed as the unauthorized practice of law. I understand that Certified Counselors are neither affiliated with the insurance industry, nor are they financial planners. They do not sell, recommend or endorse any specific insurance product, agent, insurance company or Health Maintenance Organization.

Counseling is confidential and free of charge. I understand that I may make a donation to the program, if I desire.

Furthermore, I authorize the ___________________ (local program/agency), to receive information as necessary, from other agencies or provider of services from which I’m receiving services, to complete the course of action needed regarding my public/private benefits. Such authorization shall remain valid for a period of ______days/months, from the date of signature.

CLIENT SIGNATURE                 COUNSELOR SIGNATURE

DATE                                                 DATE

Benefits Counseling Certification Program Chapter One--6/2000

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