Informed Consent

Neda Petz, Psy.D.
Licensed Psychologist (PSY33156)

Neda Petz Psychology, Inc.
(818)300-8862
dr.nedapetz@gmail.com

www.drnedapetz.com

EXPLANATION OF PRIVACY POLICIES

This document explains important policies and business practices. Please read it carefully and write down any questions that you may have so that we can discuss them together. When you sign this document, it will represent an agreement between Neda Petz Psychology, Inc. and yourself about the psychological services you will receive and our privacy practices.

DESCRIPTION OF ASSESSMENT SERVICES

There are a variety of purposes for psychological testing. Common aspects of an assessment include:

• A review of relevant records provided by the client (e.g., reports from school, relevant medical records, prior assessment reports).
• A thorough structured interview with the client and/or parent(s) or partner of the client for the purpose of obtaining background information and current concerns.
• Psychological assessment questionnaires and/or inventories include surveys to be completed by all relevant parties depending on the purpose of the assessment (e.g., parents, teachers, partner, etc.).
• A collection of assessment measures, tailored to meet the purpose of the assessment. This could include tests of cognitive ability, academic achievement, visual-motor coordination, attention span, neurological functioning, memory, processing speed, psychosocial functioning, and validity measures that assess the effort and truthfulness of the assessment.
• During a feedback session, Dr. Petz will explain the test results, diagnostic impressions, and treatment recommendations.
• The results are all combined and interpreted to create an assessment report which will provide an analysis, diagnoses, and recommendations for treatment and support.

Assessments of this nature can be beneficial for multiple reasons, including identifying specific strengths and areas for growth, receiving diagnostic clarification, and getting specific recommendations for how to proceed accordingly. There are also some potential drawbacks involved with assessments. A person may experience frustration and/or fatigue due to the demands of the tasks. The person may request breaks from testing at any time, however, in order to avoid nullifying test results it is best to continue until the assessor says it is a good time to take a break. Assessment results may not be what is expected or hoped for, and people may find the results disappointing. The assessor might not be able to render an opinion or outcome that was hoped for. Assessments may be deemed invalid due to malingering, poor effort, poor performance on validity measure(s), or other unforeseeable factors. The best way to avoid misunderstanding is to be clear at the beginning of the assessment about the reason for testing and what is needed from the results.

CANCELLATIONS

Your clinical interview, testing dates, and feedback sessions are reserved specifically for you. In the event that you must reschedule or cancel an appointment for any reason, please provide a minimum of 24 hours notice. Due to the difficulty of rescheduling appointments on short notice, it is our policy to charge a partial fee for missed appointments, regardless of the reason, if we do not receive 24-hours notice. The cancellation fee for initial intake assessment and/or feedback is $250 and the cancellation fee for an evaluation appointment is $350.

CONTACTING US 

Due to our staff’s work schedule, we are not immediately available by phone. Although we will make every effort to return calls within one business within one to two business days, we cannot guarantee that we will always be able to do so. In the case of an emergency, please call 911 and/or proceed to the nearest emergency room. 

Our staff are willing to use email to communicate with clients on a very limited basis; however, your decision to use email indicates that you understand that it is not a guaranteed secure form of communication as it can be intercepted by a third party. Emails should not be utilized to discuss clinical information but can be used for scheduling appointments.

Our staff do not communicate with or contact clients through social media platforms like Twitter, Facebook, Instagram, or Snapchat.

CONFIDENTIALITY AND RECORD-KEEPING

In general, California law and the standards of our profession guarantee that all information disclosed during a psychological assessment is kept confidential. Typically, information about your assessment will only be released to yourself and others with your written permission on a case-by-case basis. However, there are a few exceptions to confidentiality that you should be aware of:

1. If our staff have reason to suspect child abuse or neglect, we are obligated to notify the appropriate authorities
2. If our staff have reason to suspect abuse or neglect of a vulnerable/dependent adult, we are obligated to notify the appropriate authorities
3. If our staff have reason to believe that you may seriously harm yourself or another person, we must take protective action to attempt to ensure the safety of your child or others. This may include family members of the threat, warning an intended victim, notifying the police, or seeking hospitalization
4. In legal cases, a court may order testimony of records and/or ask our staff to testify
5. In some cases, I may find it helpful to consult with another professional. During a consultation, I would make every effort to protect your identity. Please be aware that other professionals are also legally and ethically bound to keep this information confidential.
6. Occassionally, I find it helpful to have doctoral level (Psy.D. and/or Ph.D.) student to facilitate in scoring (i.e., double scoring to ensure no errors are made), and/or writing summaries of individual test scores. These documents are exclusively provided within HIPAA compliant platforms and are always fully supervised. Please note that any other professional is legally and ethically bound to keep this information confidential.

You will receive a psychological report with a summary of the pertinent test results as well as a “data sheet” with test scores. You may also review notes that were taken during the assessment process upon request. Psychologists are required by law to make efforts to maintain test security. For this reason, the test questions and specific responses are confidential and will not be released to clients.

FEES AND BILLING PRACTICES

The fee for the assessment will be agreed upon at the start of the assessment and payment is expected at the initial visit unless a specific arrangement has been made otherwise. There is a great deal of variability in coverage and reimbursement policies for psychological testing. No amount of reimbursement is guaranteed. While some insurance companies may provide a portion of coverage for psychological assessment, payment is the responsibility of the client, not the insurance company. Therefore, it is very important to find out exactly what services your insurance policy covers and to what extent your policy will cover services from an out-of-network provider for those services. Clients will be provided with a statement for insurance reimbursement (often referred to as a superbill) that will typically include an initial diagnostic interview (CPT Code 90791), testing hours (CPT Codes 96130, 96132, 96136, 96146), and the final session where the results are reviewed (CPT Code 90834).  

The estimate below is the cost that has been agreed upon for your evaluation. If you have questions about this estimate, please contact Dr. Petz.

The first half of the total fee is due by the date of first session, and the second half of payment is due on the date of feedback. If fees are not collected within 30 days of feedback, the remaining balance will be sent to collections.

If there are errors in the report, please advise Dr. Petz immidately for corrections. No changes to test data, conceptualization, or diagnosis will be made.

A secondary, school-based version of reports is an additional flat rate of $500. This version includes a summary of findings, diagnoses, and academic recommendations.

PRIVACY POLICY AND HIPAA

Our privacy policies follow a federal law known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA mandates that we take certain privacy measures when storing, using, or transmitting your Personal Health Information (PHI).

In brief, Neda Petz, Psychology, Inc. may disclose your PHI for routine matters of treatment, such as communicating with other health care professionals treating you (though it is our policy to acquire a written consent from you in most instances); in matters of payment, such as billing and collecting payment; and routine health care operations, such as billing a third party insurance company. In all cases, Neda Petz, Psychology, Inc. will make efforts to appropriately restrict the amount of information shared within the organization to only that which is required for the intended use. For example, administrative staff will not have access to detailed clinical records, etc.

In Neda Petz, Psychology, Inc.'s communications with you, we may be using electronic devices such as cellular phones, text messaging and email. Neda Petz, Psychology, Inc. makes efforts to adhere to and continually refine its compliance with HIPAA best practices, including HIPAA compliant software for records and email.

I hereby acknowledge that I have carefully read and understand this Agreement and Consent to Receive Psychological Services. I agree to the policies and procedures for confidentiality, fees and billing, and the 24-hour cancellation policy. I acknowledge that I have been informed in writing of my privacy rights as guaranteed by HIPAA.