Psychological Evaluation Financial Policy & Consent

Consent for Evaluation and Treatment

I hereby give my consent for evaluation and treatment as recommended by my physician or as deemed necessary by the treating medical professional. I acknowledge that the patient or the patient's family (for minors) is responsible for any changes incurred, regardless of insurance coverage. If Sunbreak Therapy Services has a contract with the patient's insurance carrier, they will file the claim on behalf of the patient. However, if the insurance company denies payment for reasons such as no referral, non-covered services, or deductible issues, I understand that I am responsible for paying any outstanding balances.

I understand that, in some cases, certain charges billed to my insurance company may not be covered by my insurance policy. I agree to pay for any portion of the bill that is not covered by insurance. It is my responsibility to be aware of my insurance benefits and to comply with the policy's requirements.

Self-Pay (Not billing Insurance or Out-of-Network)

Regular Psychological Evaluations

Psychological evaluations will be billed at an hourly rate of $200 per hour, with the total evaluation time ranging from 5 to 15 hours, depending on the specific needs of the case. This evaluation does not include speech or occupational therapy services.

Autism Multidisciplinary Evaluations

The Autism multidisciplinary Evaluation includes assessments from three disciplines and is billed as follows:

• The psychological portion is billed at $200 per hour
• The speech-language portion is billed at $330.75
• The occupational therapy portion is billed at $352

At the time of scheduling, Sunbreak will collect a non-refundable $250 deposit, and a credit card must be kept on file. The full evaluation fee includes the diagnostic interview, testing in the respective disciplines, and the feedback session. The $250 deposit will be credited toward the total bill once the evaluation is completed.

The remaining balance will be due at the time the report is completed. An invoice will be emailed to you once the report is finalized, and your credit card on file will be charged 24 hours

Billing Insurance (In-Network)

Sunbreak will not collect a deposit for insurance billing. However, a credit card will be kept on file at the time of booking. As a courtesy, Sunbreak will contact my insurance to verify benefits. I understand it is important that I have contacted my insurance company to verify my mental/behavioral health benefits and to fully understand my financial responsibility. I am aware that some insurances may require pre-authorization, which must be obtained prior to the evaluation.

If I am scheduling a multi-disciplinary Autism evaluation, my insurance will be billed for the following:

• Speech Therapy Evaluation
• Occupational Therapy
• Evaluation Psychological Evaluation

If the evaluation is not a multi-disciplinary Autism evaluation, the charges will be based solely on the specific services provided

Attendance Policy

Sunbreak Therapy Services requires a minimum of 2 business days' notice if you need to cancel or reschedule an evaluation appointment. Specialized professionals reserve specific time for these evaluations, and last minute cancellations make it difficult to accommodate other patients. Sunbreak will only reschedule the appointment once.

For clients with Medicaid insurance:

If less than 2 business days' notice is provided, the appointment will not be rescheduled, and your referral will be closed. Sunbreak will only reschedule the appointment one time with at least 2 business days' notice.

If I fail to provide at least 2 business days' notice for canceling or rescheduling my scheduled appointment, my credit card on file will be charged a non-refundable $250 late cancellation fee in addition to the $250 deposit paid at the time of booking. The $250 deposit is applied toward any remaining balance due once the evaluation is completed.

Personal Health Information Disclosure

I have read and fully understand that Sunbreak Therapy Services may use or disclose my personal health information, without limitations, for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided, patient trend studies, and any administrative operations related to treatment or payment.

I understand that I have the right to restrict how my personal health information is used and disclosed for treatment, payment, and administrative operations, provided I notify the practice in writing.

By signing below, I acknowledge the use and disclosure of my personal information for the purposes outlined above. I understand that I have the right to revoke this acknowledgement by notifying the practice in writing at any time.

Acknowledgement and Agreement

I acknowledge that I have read, understood, and agree to the terms and policies outlined above, including the attendance, financial, and personal health information disclosure policies. I understand my rights and responsibilities and agree to comply with the outlined policies for services provided by Sunbreak Therapy Services.

By signing below, I consent to the evaluation and treatment as described, including the use and disclosure of my personal health information as necessary for treatment, payment and administrative operations.