I, as the patient named above, have reviewed the policies and procedures of West Cary Psychiatry (WCP) pertaining to computerized cognitive testing, which are available online at www.westcarypsychiatry.com or in paper form at the office at 212 Towne Village Drive, Cary, NC, 27513. I understand and agree to these policies. I understand that payment for all professional services rendered is the responsibility of the patient and parent, guardian, or other guarantor.

I have also reviewed the notice of privacy practices for WCP. I understand that as part of my health care, WCP maintains paper and electronic records that contain protected health information. I understand that WCP maintains a notice of privacy practicies that provides a complete description of protected health information uses and disclosures. The more recent version of this notice is available in the office and on the practice website. 

I, the patient (or their parent, guardian, or legal representative) understand that I have the right not to sign this form. My signature below indicates that I have received this agreement; it does not indicate that I am waiving any of my rights. I understand that I can chooose to discuss my concerns with a respresentative of WCP. 

I understand that no specific promises have been made to me by my provider or anyone at West Cary Psychiatry about the results of treatment, the effectiveness of the procedures used.

I have reviewed the issues and points in this agreement. I have discussed those points I did not understand with staff at WCP and have had all of my questions fully answered. I agree to act according to the points covered in this Agreement. I hereby agree to work with this provider and to cooperate fully and to the best of my ability, as shown by my signature below.

I authorize release of any information acquired in the course of treatment necessary to complete and file medical claims to my insurance company or Medicare on my behalf. I hereby acknowledge financial responsibility for costs of services rendered for me or for the person whose account for which I am acting as the guarantor. I authorize (assign) any insurance or Medicare benefits to be paid directly to West Cary Psychiatry, PLLC or its assignees. I am responsible for any non-covered services, supplies, copayment/coinsurances or deductibles. This acceptance and assignment will be in force for all future services by all doctors or practitioners from West Cary Psychiatry PLLC.