cpancf service agreement form - Clinical Psychology Associates of ...

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Psychotherapy can have benefits and risks. Since therapy may involve discussing unpleasant aspects of your life,you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Onthe other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to betterrelationships, solutions to specific problems, better occupational functioning, and significant reductions in feelingsof distress. But there are no guarantees of what you will experience.The diagnostic assessment and mental status will involve an evaluation of your needs by reviewing your medical,social, occupational, family and mental health history as well as reviewing current and past symptoms andsignificant life events. In some cases further formal assessment through psychological or neuropsychological testingmay be required or suggested to further assess your abilities, personality or coping skills. We will often requestrecords from other providers that are or have been involved in your care and review these to coordinate care andassist in the assessment phase. Some of these records may not be received for some time, and will be incorporatedand reviewed as received. At the end of this assessment phase, unless in certain circumstances where we performthis assessment or consultation for a third party, we will offer you our impressions based upon the information wehave gathered. In some cases we will have only a consultative or assessment role. Should you continue beyond anassessment phase, we will discuss a treatment plan and treatment options.Where applicable, you should evaluate the assessment and treatment plan information along with your own opinionsof whether you feel comfortable working with your psychologist or resident. Assessment and therapy involves alarge commitment of time, money, and energy, so you should be very careful about the therapist you select. If youhave questions about our procedures, we should discuss them whenever they arise. If your doubts persist, we will behappy to help you set up a meeting with another mental health professional for a second opinion.We have a number of brochures available regarding the nature of our assessment and therapy services and additionalinformation available on our website at CPANCF.COM.While we share offices, each of the independent practices of C. Russell Clifton, Ph.D., Domingo Cerra, M.D. andWilliam Edenfield, Ph.D. are separate entities from CPANCF and are responsible for maintaining their own policiesand procedures. Other than when these independent practices specify in writing that they are performing servicesunder contract with CPANCF, or under any Business Associate Agreement, CPANCF is not responsible fortreatment, care, services, policies or procedures of these other practice. These practices are not responsible for anytreatment, care, services, policies or procedures rendered by CPANCF other than when providing services undercontract or a Business Associate Agreement.MEETINGS/SESSIONSThe normal psychotherapy intake assessment phase, involves gathering history and your presenting complaints aswell as assessing your mental status. This may take 1 to 2, and sometimes 3 to 4, 45-50 minute sessions. This variesgreatly since we assess and treat a wide variety of patients in a wide variety of situations. We will inform you aboutunusual departures from these expectations early in our meeting(s).If we mutually agree to begin psychotherapy, we usually schedule one 45 to 50-minute session (one appointmenthour of 45-50 minutes duration) per week at a time we agree on, although some sessions may be longer or morefrequent. In some cases as you progress, we may also reduce the frequency of visits. Once an appointment hour isscheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation for atherapy session or 72 hours advance notice in the case of full-day assessments. We may make exceptions, at ourdiscretion, for emergency or unusual circumstances. It is important to note that insurance companies do not providereimbursement for cancelled sessions. We may or may not reschedule assessments at our discretion. Repeatedmissed appointments may result in termination of therapy.2
PROFESSIONAL FEESOur usual and customary fee for your first one-hour appointment, described as the “Diagnostic Assessment” or“intake” is $275.00 Hourly fees vary by therapist, but currently are between $160.00 – 180.00 per 45-50 minuteappointment. In addition to weekly appointments, we charge this amount for other professional services related topsychotherapy you may need, and $180 per hour for reviewing medical records, though we will break down thehourly cost for periods of less than one hour. Other services include report writing, telephone conversations lastinglonger than 10 minutes, consulting with other professionals with your permission, preparation of records ortreatment summaries, scoring and interpretation of testing, report writing, and the time spent performing any otherservice you may request of us.We offer a wide variety of psychological assessment services. We bill for our psychological or neuropsychologicaltesting services at a rate of $250 per hour for time seen in testing (including any time for which you are late),scoring, interpretation and report. We offer a range of such evaluations from assessment of intelligence, learningdisabilities, adjustment to pain or health difficulties, work adjustment, career interests, dementia, competency,fitness for duty, personality assessment to much more comprehensive assessments discussed below. Whenscheduling assessments we will discuss the likely time and costs required to the best of our abilities. However, someindividuals may take longer to complete the same assessment than others, and it is possible unforeseen issues mayarise. While we will make efforts to timely inform you of any substantial changes in our estimates, your out-ofpocketcosts may vary due to our being provided with incomplete, late, or erroneous information about yourcopayments and deductibles.Our office Assessments for Attention Deficit Hyperactivity Disorder and/or Learning Disability can require 1-2 daysdepending on complexity of presentation. Fees may range from $2800 - 6000, but can be less if we determine amore limited evaluation is appropriate.We may allow for discounts for prepayment on a case by case basis.We currently are in-plan insurance providers for only Blue-Cross Blue Options, PPC and PPO products (not HealthOptions or HMO products). It is our understanding per their communication with providers, our professionalorganization’s contact with their administration and per their policies services to determine IQ, mental retardation,educational testing for learning disabilities and any court-ordered services are not covered and are not to be billed tothem. By seeking services at our office you are agreeing that you will privately pay for any of the above services,and unequivocally and without right of revocation will not request we bill these services to insurance.Neuropsychological evaluations for developmental or acquired brain injury often require 1 ½ to 2 ½ days of testingand in rare occasions more. These are usually scheduled for 9:00 a.m. to 5:00 p.m. with an hour for lunch.Additional time is billed for scoring and interpretation (report), approximately ½ hour of scoring and interpretationrequired per hour of testing (possibly more in cases where civil or criminal claims or litigation is involved). Fees forneuropsychological evaluation and review of records can range from $6000- 8000 for evaluations. In cases whichinvolve complex determinations and a great deal of research, medical record review, or forensic consultation feescan reach $10,000 - 15,000 or more.Workers Compensation Neuropsychological or Psychological Evaluations and Psychological or NeuropsychologicalIndependent Medical Evaluations are usually pre-arranged for payment with your attorney or an insurer/carrier or itsrepresentative.If you become involved in legal proceedings that require our participation, you will be expected to pay for all of ourprofessional time set aside for preparation, deposition, testimony, including preparation and transportation costs,even if we are called to testify by another party. Note that depositions and testimony canceled less than 72 workinghours in advance will incur full fee for the time that was reserved. Professional charges for preparing for testimony,legal involvement, including completing any forms requiring professional opinions, are charged on a basis of $250per hour. In case of deposition or court testimony within 1.5 hours of our Gainesville office charges are $375.00 perhour, portal to portal from our Gainesville office for actual or reserved time (whichever is greater). For out of town3
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