I give my consent to West Psychological, PLLC and/or staff to contact the following person in the event of an emergency:

I have received a copy of and agree to “West Psychological Services, PLLC Policy Agreement” and hereby request and authorize West Psychological Services, PLLC (hereafter referred to as “WPS”) and its respective personnel to provide mental health services/treatment to me or my dependent (if patient is a minor). I understand that mental health services/treatment may include psychological assessment and/or psychotherapy. I am agreeing only to those services that WPS is qualified to provide within the scope of the provider’(s) license, certification, and training or the scope of those provider(s) directly supervising the services received by me. I also understand that, at any time, I can terminate this consent for treatment by putting such request in writing.

FINANCIAL AGREEMENT I understand that I am responsible for all charges for services provided by WPS. I will pay in full, at the time of service, for all services rendered on my behalf or my dependent’s behalf. WPS will provide a Billing Statement that I can file with my insurance provider for reimbursement. If my mental health insurance coverage is through any insurance network that requires a co-pay, I will pay the co-pay at the time of service and WPS will submit a claim to the insurance network. I agree to provide accurate and updated healthcare/insurance information to WPS and hereby give consent to WPS to release any required information to my healthcare insurance to assist in the processing of claims, including protected healthcare information in accordance with the Health Insurance Portability and Accountability Act (HIPAA). I also acknowledge and understand that I am responsible for any charges not covered by my health insurance.

NOTICE OF PRIVACY POLICIES I hereby acknowledge that I have been offered a copy of the “Notice of Privacy Policies” and understand the information included in this document. I am aware that a copy of this notice will be given to me when I ask for a copy.

Reports and Other Communications I acknowledge that all final reports, requests for documents, and specific letters can take up to 12 weeks to prepare and distribute.

I hereby authorize WPS to communicate with me via telephone, email, and/or text message for purposes related to my care, including appointment reminders, scheduling, and other relevant information.

I understand that:

• These communication methods may not be fully secure or confidential.
• There is a risk that information could be intercepted or accessed by unauthorized parties.
• I may revoke this consent at any time by notifying WPS in writing

By agreeing to participate in telehealth/telepractice services, I understand and acknowledge the following:

Nature of Services:
Telehealth involves the use of electronic communication (e.g., video conferencing, phone calls) to provide psychological services remotely. These services may include assessment, therapy, consultation, or other related activities.

Confidentiality:
Reasonable efforts will be made to protect the confidentiality of all telehealth communications. However, I understand that there are inherent risks, such as potential breaches of privacy due to technology failures or unauthorized access.

Technical Requirements:
I am responsible for ensuring I have access to the necessary equipment and internet connection to participate in telehealth sessions. If technical difficulties occur, sessions may be rescheduled or conducted through alternative means (e.g., phone).

Emergency Situations:
Telehealth services are not designed for emergencies. If I experience an urgent or life-threatening situation, I will contact 911 or visit the nearest emergency room.

Consent to Participate:
I consent to receiving telehealth services and understand that I can withdraw this consent at any time by notifying the provider in writing. I also agree to abide by the rules and expectations established for telehealth sessions.

Recording Prohibition:
I understand that recording telehealth sessions is not permitted unless explicitly agreed upon by all parties.
By participating in telehealth services, I confirm that I have read, understood, and agree to the above terms.

I authorize West Psychological Services PLLC to apply for benefits from my insurance carrier and further authorize payment directly to West Psychological Services PLLC who accepts assignment of the healthcare/medical benefits, for services rendered.

I authorize the release of health/medical information required by my insurance carrier or its designated review agent, in order to determine benefits to which I may be entitled, or to designated agents of West Psychological Services PLLC. 

This entire authorization is valid for all episodes of care rendered by all providers associated with West Psychological Services PLLC. I permit a copy of this authorization and agreement to be used in place of the original.

Beneficiary: I request that payment of authorized Medicare benefits be made on my behalf to West Psychological Services PLLC, for all services furnished to me by West Psychological Services PLLC. I authorize any holder of medical information about me to release to the Health care Financing Administration and its agents any information necessary to determine benefits or benefits payable for related services. 

Testing TimeLine-What to Expect:

1st: Appointment - Patient Intake: Discuss concerns and issues with psychologist. This is a 30 minute (approx appointment which is subject to a copay/payment at time of service. (Patient/Parents of Patient Only 2nd Appointment - Testing Session: Patient meets with psychologist for formal evaluation (scheduled by the

psychologist during the 1st appointment Testing Authorization is Requested: Authorization from insurance company must be in place for testing to occur (this can take 2 weeks or more (depending on the insurance company and individual issues) for approval from insurance company The office will submit the authorization request after the first meeting. Testing of Patient: Testing time will vary and if necessary could occur over multiple sessions. The dates and times will be determined by the schedule of the psychologist and patient. Copay/Payment of testing is due at time of testing (note: Only (1) copay required even if several days are needed to completetesting Test results/feedback with patient/parent of patient: - Typically following completion of testing the patient or his/her parents will meet with psychologist to go over the results of assessment. This is not always possible and a 3rd appointment will be required. This 3rd appointment is subject to copay/ payment at time of service and not included in the total testing cost. (Patient/Parents of Patient Only Report from psychologist: As report content, length, and complexity can vary depending on the individual assessed, receipt of the report may take up to 12 weeks. This time can be lengthened should paperwork not be returned, medical/school/collateral records are not obtained within a timely fashion, or the complexity of the case requires additional consultation, testing, scoring, and interpretation. If requested; report will be emailed to the email provided or mailed following Patient feedback. If the patient was referred by a physician, a copy will also be forwarded to the referring physician. Important Information about Testing and Insurance: Insurance companies and policies HIGHLY vary on which tests they approve and the number of hours they allow. Any tests requested by an individual or their family that an insurance company considers primarily for educational purposes (e.g., psychoeducational tests, academic/achievement tests, certain developmental tests, or reading batteries) will NOT be covered under your policy. Our contracts with a number of insurance companies preclude us from filing any educational testing hours. As such, the individual or families of the patient will be responsible for covering these hours. If you are seeking testing only to assess IQ, giftedness or placement in a gifted or other educational program, or court ordered psychological testing, this testing is NOT covered by insurance as they are not considered medically necessary. Please request information regarding the self-pay rate for testing. Psychological testing & assessment sometimes requires a special authorization from your insurance company. As stated by the insurance companies, this authorization is not a guarantee of payment. The authorization for testing does not include the intake or feedback appointments, this will be covered under the patient's therapy sessions authorization. If it is felt that certain tests are needed in order to provide an accurate diagnosis but are not covered services by your insurance, and you request the tests to be performed, the additional time will be billed to you at the insurance contracted rate per hour. Payment is due in full on the day of testing. If the testing balance has not been paid by the feedback appointment, West Psychological Services, PLLC reserves the right to postpone the testing feedback session until the full balance due has been satisfied. West Psychological Services, PLLC also has the right to withhold testing reports until payment is made in full. 

By signing below, I have read, reviewed, and agree to the Psychological Testing Agreement provided by West Psychological Services, PLLC and (if applicable) request the additional testing not covered by the patient's insurance company.

This form is intended to provide information about psychological services and to obtain your informed consent for treatment. Please read it carefully and discuss any questions or concerns with your psychologist before signing. Description of Services Psychological services may include evaluation, therapy, counseling, consultation, and other interventions tailored to address your or your child's specific needs. Your psychologist will work with you to develop a treatment plan to help achieve your goals. Limits of Confidentiality Information shared during sessions is confidential and will not be disclosed without your consent, except in the following circumstances, as required by Tennessee law: If there is suspicion of abuse or neglect of a child, elderly, or disabled individual. If there is a threat of serious harm to yourself or others. If a court orders the release of records or testimony. In cases of professional consultation or supervision (de-identified information only If disclosure is necessary, every effort will be made to discuss this with you beforehand unless it is an emergency situation. Fees and Payment Policy Payment is due at the time of service unless other arrangements have been made. Missed appointments or cancellations with less than 24 hours' notice may incur a fee. Services may be covered by your insurance; please verify coverage and provide necessary information. Rights and Responsibilities You have the right to participate in your treatment planning and to ask questions at any time. You may discontinue treatment at any time; however, it is recommended that you discuss your decision with your psychologist to ensure proper closure. Psychologists are required to abide by the ethical standards of the American Psychological Association (APA) and Tennessee state laws governing psychological practice. Consent for Minors (if applicable) If the client is a minor, the parent(s) or legal guardian(s) must consent to treatment. The psychologist will discuss with parents or guardians what information will remain confidential to support the therapeutic process. Emergency Services Psychological services are not designed for 24-hour crisis intervention. If an emergency arises, please contact 911 or go to the nearest emergency room. Acknowledgment and Consent I, the undersigned, have read and understood this consent form. I agree to participate (or allow my child to participate) in psychological services provided by Rebecca West, PhD. I understand that I may revoke this consent at any time, in writing, except where action has already been taken.

I, the undersigned, hereby authorize West Psychological Services, PLLC to use or disclose protected health information in the manner described in this authorization for the following patient:

I understand that my signature on this form is voluntary and that not signing will not affect the ability to receive treatment at this practice. | understand that this release will expire in 180 days, unless revoked by me which I have the right to do at any time. I understand that any revocation will not apply to any PHI that has already been released in reliance to this authorization and to PHI created expressly for disclosure to the person/entity listed below. I understand that the PHI disclosed may be subject to re-disclosure by the person/entity receiving it and no longer protected by federal privacy regulations except in the case of drug/alcohol treatment which must be clearly stamped "Do not re-disclose" and protected accordingly under 42 CFR Part 2. I understand that any questions I have about the use or disclosure of this PHI can be directed to West Psychological Services, PLLC at any time.

I give permission for West Psychological Services to:

I authorize disclosure to the following person(s)/entity(ies):

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this Notice please contact our Privacy Officer who is Rebecca West, Ph.D

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician's practice. Following are examples of the types of uses and disclosures of your protected health information that your physician's office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician. Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities. We will share your protected health information with third party "business associates" that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you. We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object: We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include: Required Bv Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.

Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight: We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects or problems, biologic product deviations, to track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required. Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose protected health information, SO long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on the premises of our practice, and (6) medical emergency (not on our practice's premises) and it is likely that a crime has occurred. Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual. Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized. Workers' Compensation: We may disclose your protected health information as authorized to comply with workers' compensation laws and other similar legally-established programs. Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you. Uses and Disclosures of Protected Health Information Based upon Your Written Authorization Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.

Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgement, determine whether the disclosure is in your best interest. Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi. Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for SO long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice uses for making decisions about you. As permitted by federal or state law, we may charge you a reasonable copy fee for a copy of your records.

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by [describe how patient may obtain a restriction. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer. You may have the right to have your physician amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for SO long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occur after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint.

YoucontactourPrivacyOfficer,RebeccaPh.D West,at may rwest@westpsychologicalservices.com for further information about the complaint process.

This notice was published and becomes effective on January 22, 2014. Resent review on January 22, 2024.