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MISSED APPOINTMENTS: IF YOU ARE UNABLE TO KEEP AN APPOINTMENT,
PLEASE NOTIFY OUR OFFICE IMMEDIATELY. IF AN APPOINTMENT IS CANCELED
OR MISSED WITHOUT 24-HOUR ADVANCE NOTICE, YOU WILL BE CHARGED
FOR THIS SESSION TIME. WE HAVE A 24-HOUR-A-DAY PHONE COVERAGE
THROUGH OUR OFFICE AND AFTER-HOURS VOICE MAIL. INSURANCE DOES
NOT PAY FOR MISSED APPOINTMENTS; THEREFORE, YOU WILL BE FINANCIALLY
RESPONSIBLE FOR THE FULL FEE.
RESPONSIBILITY: The client (or referring parent in the
case of minors) is considered responsible for payment of our
professional fees. It is the client's responsibility to know
the amount of their deductible and/or co-payment. When we
are requested to bill a third party, such as a divorced spouse,
relative, or insurance company, and that third party fails to
make timely payments, payment is expected from the referring
parent that signed the consent for services. The client will
be responsible for claims that are denied due to "filing
past the insurance carrier's time limit" that is the result
of failure by the client to inform this office of changes in
insurance coverage.
We appreciate the opportunity you have provided for us to be
of service to you. If you have any questions, please discuss
them with us. I have read, understand, and agree with the Fee
Information guidelines outlined above.
______________________
___________
Client (or parent) Signature
Date
PLEASE READ AND SIGN
I, ____________________ , give my consent for to receive educational/placement
consulting services from Carolina Psychological Associates,
P.A. I understand and agree to pay $100.00 per hour
for consulting services, $125.00 per hour for psychological
testing, $300.00 for school placement research fee, $300.00
for a scholarship search fee, and for any appointments
that are missed or canceled less than 24 hours in advance. A
$20.00 fee will be charged for checks returned for non-sufficient
funds. I understand that I am responsible for any fees incurred
but disallowed for any reason by my insurance company, and for
any agency fees/court costs involved in collecting on my past
due account. I understand that if I am unable to keep
an appointment, I agree to notify Carolina Psychological Associates,
P.A., with at least 24 hour advance notice. I agree that I am
financially responsible for any phone calls longer than 15 minutes.
Payment is required at the time services are provided; however,
insurance information will be obtained at the first visit and
insurance will be filed as a courtesy to me. Insurance will
be filed for psychoeducational testing only!
Educational/placement consulting services may involve meeting
with parents and/or the youth, reviewing educational, treatment,
and medical records, and providing a minimum of 12 colleges
(or 3-5 special needs program) for parents to visit and contact
for their final choice. Parents and students are solely responsible
for making the final choice of what they deem to be appropriate.
Educational/placement consulting is not designed to be therapy
or a substitute for therapy and treatment and cannot guarantee
acceptance or the student's progress.
Release and Assignment: I hereby authorize any plan
benefits to be paid directly to Carolina Psychological Associates,
P.A., and I understand that I am financially responsible for
non-covered services, including those for which authorization
or payment is denied, either by EAP/Managed Care plan or payor.
If a claim is made by me or by Carolina Psychological Associates,
P.A., to any insurance company or companies, or to any third
party payor, I do not object to the release by mail, fax, telephone
or computer modem, any records or other information about my
child, or the services which are provided, including, without
limitation, the complete case record, information concerning
any personal, psychological and medical history, information
concerning the diagnosis and treatment by Carolina Psychological
Associates, P.A., and information concerning billing and payment
for such services. I agree that all such information shall be
subject to review by such insurance company or third party payor
during the period of my child's treatment by Carolina Psychological
Associates, or at any time thereafter.
If the parents of this child are separated or divorced, and
there is joint custody, I understand and consent to the other
parents' notification of services of my child as advised by
the N.C. Attorney General's Office.
_________________
Parent or Guardian Signature Relationship to Minor
_________________
Date
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