Informed Consent

Informed Consent for Financial Responsibility & Psychological Services Guarantee of Payment

Financial Responsibility

I understand and agree that I will be charged a fee for all direct and indirect professional services rendered on my behalf. My standard hourly rate for clinical services is $200.00. Billable services may include but are not limited to any and all of the following: direct (face to face) therapeutic series, clinical interviews, behavioral observations, psychological testing or consultation services. More limited or extended service will be billed on a prorated basis. Phone calls initialed by or for the patient will be billed at the standard professional fee, per amount of time; there will be no charge for phone calls less than five (5) minutes in duration.

Testing

Psychological testing is sometimes necessary and can be extremely helpful in understanding the nature and extent of academic, learning, emotional and or psychological difficulties. Evaluations usually require five to ten hours of services. For every hour of direct testing, another hour is required for scoring, analyzing and interpreting the results. The per hour rate of psychological evaluation is $200.00 per hour. In addition to verbal feedback, an optional comprehensive report can be prepared at your request. In our experience, insurance carriers do not cover this comprehensive report and therefore the patient is responsible for this cost.

Cancellations and Check Returns

I require 24-hour notice for appointments cancelled. If you are canceling without a 24 hour notice you will be charged for the time. Insurance will not cover cancellation charges. For returned checks, you will be charged $25.00 plus the fee currently charged by my banking institution. Restitution must be made in cash.

Acknowledgement of Responsibility

It is your responsibility to make full payment at time of service. In lieu of this you will guarantee full payment with a credit card. In the event that I am entitled to benefits of any type arising out of any insurance policy, I hereby assign any insurance benefits to Goodings Grove Psychology Associates (GGPA). You will be responsible for payment of any changes that are not covered by insurance. Any problems that occur with insurance reimbursement are your responsibility to solve with the insurance company. You authorize Goodings Grove Psychology Associates (GGPA) to charge your credit or debit card for any unpaid balances under the following conditions: If your insurance carrier does not pay within 30 days after the insurance claim is filed, you will be notified by letter or phone. It is then your responsibility to pay the account in full and work out the discrepancy with your insurance company. Past due accounts may be referred to a collecting agency. You authorize the release of information to the collection agency and or attorney as necessary for billing and collecting purposes.

Release of Information

Communications may occur by phone or in writing with your insurer for the purpose of conducting utilization reviews. Utilization reviews may require the release of written or verbal confidential information such as progress notes, treatment reports and psychological reports. You are directing GGPA to exchange information regarding your case, including release of a psychological report, to agencies, doctors, therapists, or to anyone you authorize in writing. By authorizing release of information, I understand that I am waiving the confidential nature of the patient-provider relationship. I also authorize the release of information as necessary for the purpose of GGPA obtaining consultation regarding my evaluation and/or treatment. I authorize the release of any and all information requested by my insurance carrier for the purpose of processing my insurance claim and obtaining payment for services. In authorizing the release of information to any insurance company or other third party, I understand that the information may become part of the third-party records and that GGPA can no longer control any subsequent release of information. The only way you can absolutely assure the confidentiality of your treatment is to pay for the services yourself.

Consent for Psychological Services

I hereby voluntarily give my consent to psychological services provided by GGPA. The consent applies to myself, my child, and/or my family. Because I have the right to refuse services at any time, I understand and agree that my continued participation implies informed consent.

Limitations of Services

GGPA provides outpatient psychological services only. GGPA does not provide emergency services. Should you require emergency services after hours, please dial 911.

Assumptions of Risks

I understand that the potential benefits of undergoing psychological services may include improvement in psychological functioning of myself or child and/or an increased understanding of myself and/or child. I understand that the potential risks may include possible disagreement with opinions offered to me, and possible emotional distress concerning my situation. I understand that alternative procedures include services provided by another psychologist, psychiatrist, or mental health professional. I understand that while the evaluation and/or treatment will be based upon known psychological principles and research, the practice of psychology is not an exact science. I acknowledge that no guarantees have been made to me concerning the results of evaluation or treatment provided by GGPA.

Statement of Understanding

I certify that I have read this form or that it has been read and explained to me in terms that I understand. My questions have been answered to my satisfaction and all statements of which I do not approve have been stricken by mutual agreement. I understand I may revoke this consent at any time except to the extent that action has been taken in reliance upon it. I understand that my consent for release of information will be considered valid for twelve (12) months after my last appointment. I acknowledge that I voluntarily consent to the preceding conditions. By signing this form, I understand and agree with the terms and conditions of this form.

Guarantee of Payment

I understand and agree that Goodings Grove Psychology Associates (GGPA) may charge my credit cards or debit card in the event My insurance carrier fails to pay within 30 days of filing (as required by state law)I have been notified by letter or phoneI have been allowed to pay my bill with 10 daysI have failed to pay within those 10 days.This guarantee of payment is valid for twelve consecutive months after my last visit unless I cancel this authorization through written notice to Goodings Grove Psychology Associates (GGPA).