Please be informed that Bay Area Psychological Consultants files insurance as a courtesy, and it is in no way a guarantee that your insurance company will pay for services rendered. All claims are subject to the written conditions of your policy. You, as the patient, are ultimately responsible for the account and any follow-up contact needed with your insurance carrier. Your signature is required in order to file insurance and receive services. 

 

I agree to assign all insurance benefits not to exceed total charge to my psychotherapist at Bay Area Psychological Consultants. I agree for any information to be released to insurance companies and/or sponsoring agencies for the purpose of verifying outpatient and/or inpatient diagnosis, treatment and other data. I hereby agree to be responsible for the cost of any non-covered services as notified by a periodic statement and my explanation of benefits.

 

I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered at the time of service. 

APPOINTMENTS/CANCELLATIONS/NO SHOWS

There is a great demand for mental health services, and many of our providers have waiting lists to be seen.  Each missed appointment represents a lost opportunity to see another patient who could have benefitted from the session.  We assess no show/late cancellation fees in hopes that patients will be more mindful of their appointment commitments and help ensure efficient services for everyone.

In the event you cannot keep your appointment, 2 business days notice is required. If you miss your appointment or do not cancel within 2 business days notice prior to your appointment, you will be charged a $75 fee (increasing by $25 each missed appointment or late cancellation to a max of the full fee per appointment). If you have an appointment on a Monday, you must cancel by Thursday at 5PM CST to avoid a fee. If you cancel on Saturday or Sunday, you will be charged a late cancellation fee.  The fee is automatically assessed when an appointment is cancelled without sufficient notice. The fee will be removed if a doctor's note is provided.

If you have several standing appointments and you miss two sessions in a row without contacting the office, all future sessions will be cancelled without notice.  You are responsible for remembering your appointments.   

ARRIVAL TIME 
All patients should arrive prior to their appointment start time to confirm current information on file and pay any fees due.  Patients that do not arrive within 10 minutes of their scheduled appointment start time may have their appointment rescheduled and the late fee/no show fee will be assessed to their account.  

FINANCIAL RESPONSIBILITY 
The patient (or guardian) is ultimately responsible for payment of charges for services received from this practice, including those covered by insurance.  As a convenience, this practice will submit claims for reimbursement to your insurance provider; however, all payment responsibility is ultimately the patient’s responsibility. All copays, coinsurance, and/or deductibles are due at time of service. If a minor child/dependent attends an appointment without parent and/or guardian present, payment must be received prior to the appointment.  All patients will be required to keep a valid credit card on file for payment of copays, coinsurance, deductibles, appointment fees not covered by insurance, no show fees, cancellation fees, and/or returned check fees.  See credit card policy for details. 

PATIENT INFORMATION 
The patient is ultimately responsible for letting the office staff know of any change of information.  Please update any and all information as it arises. 

OFFICE HOURS AND PHONE CALLS 
Our office hours are 8:00 A.M. to 4:00 P.M. Monday through Thursday, and on Friday from 8:00 A.M. to 12:00 P.M.  We are closed for holidays and may have modified hours during holidays or staff shortages.  If you call our office and get a recording, please leave a voicemail or text the phone number, and your request will be responded to as soon as possible. For urgent situations, you should call the crisis line at 988.  In life threatening situations, you should go to the nearest emergency room for immediate care or call 911.   

CONFIDENTIALITY 
Therapy information is usually only released after you have given permission by signing a release form.  There may be, however, certain times that the provider would be required by ethics and law to break the confidentiality.  Those situations would be (A) when there is an immediate threat of self-harm or harm to others, (B) when there is suspected or actual abuse and/or neglect of a child, the elderly, and/or an individual with disabilities, and (C) legal court orders to provide information. Additional instances in which confidential information can be released are discussed in our Notice to Patients Regarding Privacy of Health Information. 

With your signature below, you acknowledge that you have read, understand and agree to the above terms. Additionally, I have received, read, and agree with the office’s policies and practices regarding the privacy of my personal health information as described in the Notice to Patients Regarding Privacy of Health Information Practices with the notice of office policies and practices regarding the privacy of my personal health information. 

Bay Area Psychological Consultants is committed to meeting your mental healthcare needs and keeping your insurance and other financial arrangements as simple as possible. Due to rising administrative costs, we require that ALL patients keep a debit/credit card on file.

I agree to provide the above practice and/or its designated payment agent with my credit/debit card information. I am responsible for providing the practice with updated credit card information should my card become invalid for any reason.

I authorize the following charges to my Visa, Mastercard, American Express or Discover Card for the following:

• Late cancellation fees or no show fees.
• Coinsurance/copay/deductibles for services provided.
• The balance of fees denied by my insurance company or not paid by my insurance company within 60 days of date of service up to $250. I will be contacted by the practice for all balances over $250 and will be responsible for making arrangements for payment of fees exceeding $250.
• Insufficient check amounts plus any insufficient check fees that may be occurred per bad check.

I authorize Bay Area Psychological Consultants to charge the credit card indicated in this authorization form according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, / understand that the payments may be executed on the next business day. / understand that this authorization will remain in effect until / cancel it in writing, and / agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated above. / certify that / am an authorized user of this credit card and that / will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.

Understanding Your Health Record & Information

Federal regulations developed under the Health Insurance Portability and Accountability Act (HIPAA) require that this Practice provide you with this Notice Regarding Privacy of Personal Health Information (PHI). A record of your visit is made each time you visit healthcare providers. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

· Basis for planning your care and treatment.

· Means of communication among other health professionals who contribute to your care.

· Legal documentation describing the care you receive.

· Means by which you or a third party payer can verify that services billed were actually provided.

· A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you:

· Ensure its accuracy.

· Better understand who, what, when, where, and why others may access your health information.

· Make more informed decisions when authorizing disclosure to others.

 Our Responsibilities

This Practice is required to:

· Maintain the privacy of your health information.

· Provide you with a notice as to our legalduties and privacy practices with respect to information we collect and maintain about you.

· Abide by the terms of this notice.

· Notify you if we are unable to agree to a requested restriction.

· Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will inform you.We will not use or disclose your health information without your authorization, except as described in this notice.

 Use & Disclosure of PHI in Treatment, Payment, & Health Care

Your Personal Health Information (PHI) may be used and disclosed by this Practice in the course of providing treatment, obtaining payment for treatment, and conducting healthcare operations. Disclosures may be in writing, electronically, by facsimile, or orally. Additionally, the Practice may also use your PHI to remind you of an appointment, inform you of potential treatment alternatives, and inform you of health-related benefits or services that may be of interest to you.

 Other Uses or Disclosures Permitted Without Authorization

In addition to treatment, payment, and healthcare operations, this Practice may use or disclose your PHI without your permission or authorization in certain circumstances including:

· When legally required to comply with any federal, state, or local laws that involve disclosure of your PHI.

· When there are risks to public health as permitted or required by law such as for the purpose of preventing or controlling disease, injury, or disability.

· To report abuse, neglect, or domestic violence if it is believed that the patient or others in relationship with the patient is the victim.

· To conduct health oversight activities such as audits, or civil, administrative, or criminal investigations, proceedings, or actions.

· For judicial and administrative proceedings authorized by an order of a court or administrative tribunal.

· For specialized government functions if you have served as a member of the armed forces or in the Department of State and disclosure is requested by you or requested by US military command authorities.

· To deceased patients’ family members as mandated by state law or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent.

· In medical emergencies in order to prevent serious harm.

· To close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

· For public safety if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public

Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

· Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522.

· Obtain a paper copy of the notice of information practices upon request.

· Inspect and copy your health record as provided for in 45 CFR 164.524.

· Amend your health record as provided in 45 CFR 164.528.

· Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528.

· Request communication of your health information by alternative means or at alternative locations.

· Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

· Be notified if a breach of PHI occurs.

For More Information or to Report a Problem

If you have questions and would like additional information, you may contact the Privacy Officer at our office at the address listed above. If you believe your privacy rights have been violated, you can file a complaint with the Director of Health Information Management or with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

I authorize Bay Area Psychological Consultants to provide notice to me by telephone or verbally in the event of a breach of my protected health information (PHI) by Bay Area Psychological Consultants. Such conversation will be documented by Bay Are a Psychological Consultants.

Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Final Rule modifying the HIPAA Privacy, Security, Enforcement and Breach Notification Rules, the verbal or telephonicnotice provided to me pursuant to this authorization shall not be simply for the administrative convenience of Bay Area Psychological Consultants.