INFORMATION COLLECTION FORM
CONFIDENTIAL

I, the undersigned, hereby agree that, excluding Worker’s Comp and Medicaid, I will guarantee payment for services rendered by the above-named doctor.  I hereby authorize payment directly to same, of the benefits otherwise payable to me but not to exceed the doctor’s regular charges for this service.  I understand I am financially responsible to the doctor for charges not covered by this agreement, and I agree that the bill will be paid upon receipt of a statement unless other arrangements have been made with our office.  I also understand that, should a collections process become necessary, I am responsible for all expenses connected with their process.  I further authorize the release of information for insurance purposes.

PATIENTS’ RIGHTS AND RESPONSIBILITIES STATEMENT

STATEMENT OF PATIENTS’ RIGHTS

Patients have the right to:

• Be treated with dignity and respect.
• Fair treatment, regardless of their race, religion gender, ethnicity, age, disability, or source of payment
• Their treatment and other member information kept private. Only where permitted by law, may records be released without member permission.
• Easily access timely care in a timely fashion.
• Know about their treatment choices. This is regardless of cost or coverage by the member’s benefit plan.
• Share in developing their plan of care.
• Information in a language they can understand.
• A clear explanation of their condition and treatment options.
• Information about Magellan, its practitioners. services and role in the treatment process.
• Information about clinical guidelines used in providing and managing their care.
• Ask their provider about their work history and training.
• Give input on the Members’ Rights and Responsibilities policy.
• Know about advocacy and community groups and prevention services.
• Freely file a complaint or appeal and to learn how to do so.
• Know of their rights and responsibilities in the treatment process.
• Receive services that will not jeopardize their employment.
• Request certain preferences in a provider.
• Have provider decisions about their care made without regard to financial incentives.

STATEMENT OF PATIENTS’ RESPONSIBILITIES:

Patients have the responsibility to:

• Treat those giving them care with dignity and respect.
• Give providers information they need. This is so providers can deliver the best possible care.
• Ask questions about their care. This is to help them understand their care.
• Follow the treatment plan. The plan of care is to be agreed upon by the member and the provider.
• Follow the agreed upon medication plan.
• Tell their provider and primary care physician about medication changes, including medications given to them by others.
• Keep their appointments. Members should contact their provider(s) as soon as they know they need to cancel visits.
• Let their providers know when the treatment plan isn’t working for them.
• Let their provider know about problems with paying fees.
• Report abuse and fraud.
• Openly report concerns about the quality of care they receive.

CONFIDENTIALITY, PRIVILEGED COMMUNICATION, AND DUTY TO WARN OR PROTECT

Federal and State of Georgia laws assure that everything a patient tells their mental health professional is to remain confidential and is considered privileged communication.  Any information a mental health professional has regarding the patient can only be released with the signed, written consent of the patient (or patient’s parent or legal guardian in the case of a individual).  Thus, confidentiality and privileged communication are your rights, guaranteed under State and Federal laws.

There are, however, two exceptions in which the mental health professional’s social responsibility is given precedence over these rights.  If a patient intends to harm him or herself, or another individual, the mental health professional has the responsibility and duty to protect the patient, or warn the person to whom harm is intended.  Such action by the mental health professional may require that confidentiality be broken.  Of course breaching confidentiality would be the last resort, occurring only after all reasonable efforts to resolve the situation had failed, and would be limited to the necessary information required to ensure safety.

State of Georgia law also requires that mental health professionals report all incidents of any type of suspected individual abuse to appropriate agencies.

I have read the above and understand my rights and the mental health professional’s social responsibility.

BILLING AND FINANCIAL POLICY

Diagnostic Interview - First Visit - $250.00 - based on 45-50 minutes of actual contact time, and additional time being used for developing a treatment plan, charting, reviewing records, etc.

Therapy Sessions - $175.00 - are based on one hour and defined as 45-50 minutes of actual contact time, with the remaining 5-10 minutes being used for charting, writing progress summaries, etc.  A half hour - $85.00 - is defined as 25 minutes of actual contact time.  Therapy sessions which last longer than 50 minutes will be billed accordingly.

Missed Appointments and Cancellations are not considered for payment by insurance companies, you are, nevertheless, responsible for paying the normal hourly rate for missed appointments and cancellations if there is less than 24 hours notice.  Our telephones are answered 24 hours a day, 365 days a year, either by our office personnel or voice mail.  If you arrive late for your appointment, you will be billed for the time scheduled.  The appointment will still conclude on time.

Consulting with another professional, phone calls and all other services are billed at the hourly rate, to the quarter hour. 

Telephone Calls are normally brief and are not usually charged at the time.  However, should they accumulate to more than 15 minutes of the psychologist’s time, it will be billed accordingly.  Most insurance companies do not reimburse for telephone consultations.

Forensic Services (i.e., services used for legal purposes) are billed at a higher rate due to the preparation required and unpredictability of scheduling court appearances.  The higher rate applies for all time spent interviewing, assessing, waiting to testify, testifying, and preparation and will be charged when subpoenaed, giving a deposition, and for all other court-related services the psychologist provides.  WE CANNOT ACCEPT ASSIGNMENT FOR INSURANCE FOR ANY SERVICES TO BE USED FOR LEGAL PURPOSES OR ANY OTHER NON-MEDICALLY NECESSARY SERVICES.

PAYMENT:   Payment in full - less the amount insurance will pay - is required at the time of service.  No further services will be scheduled if your account becomes two or more payments behind (i.e., for two hours of service).

INSURANCE:   We will file your insurance claims only if we are contracted providers with that company.  After you have met your deductible for the year, we will accept the assignment (i.e., reimbursement directly from your insurance company).  However, deductibles, co-payments and all fees not covered by your policy are still due at the time of service.

PRECERTIFICATION OF INITIAL APPOINTMENT IS YOUR RESPONSIBILITY.  Your doctor will take care of any pre-certification necessary for ongoing treatment.  It is also your responsibility to know your benefits - co-pay, deductible, authorization requirements, referrals, etc. - prior to your appointment.

NOTE 1: In cases of divorce and/or separation, the parent who originally brought the individual in for services is responsible for paying this office, regardless of which parent is legally responsible for insurance coverage and medical bills as established by a divorce or any other agreement.  Assignment from the non-custodial parent’s insurance carrier will be accepted only after this office has his/her signature on file.

NOTE 2: Former patients returning for treatment who have had an unsatisfactory payment history or have been turned over to our collection agent will be seen on a CASH ONLY basis.  We’ll be glad to give you the necessary forms for reimbursement directly from your insurance company to you.

I HAVE READ AND UNDERSTAND THE ABOVE BILLING POLICY.  I AGREE TO PAY FOR SERVICES UNDER THE CONDITIONS AND SPECIFICATIONS SET FORTH IN THIS BILLING POLICY AND ACKNOWLEDGE THAT I AM RESPONSIBLE  FOR PAYMENT OF ALL SERVICES PROVIDED, REGARDLESS OF INSURANCE COVERAGE, EXCLUDING MEDICAID AND WORKER’S COMPENSATION; INCLUDING COLLECTIONS/COURT COSTS SHOULD THAT PROCESS BECOME NECESSARY IN THE SETTLEMENT OF MY ACCOUNT.

CONFIDENTIAL

TREATMENT CONSENT FORM

Explanation of Consent Form and Orientation of services:

This treatment consent form covers all procedures that are not of a nature to require a special consent, and it provides protection for the procedures performed by the professional staff of Progressive Consumer Counseling Services, LLC (hereafter known as PCCS).  This form documents that the client has consented to treatment at PCCS, including but not limited to psychotherapy and counseling.  This allows the professional staff at PCCS to provide services to you.

This form provides evidence that no guarantee is made by any professional at PCCS concerning the outcome of treatment.  There is no guarantee that treatment will be successful.  This form also provides evidence that consent is given only after a full explanation has been provided by the staff at PCCS.  If you have any questions concerning this or any other matters, it is your responsibility to ask your therapist.  By signing this form, you acknowledge that you understand your consent to treatment as explained in this form.

By signing this form you are also acknowledging that you have received orientation and overview of the services that you are receiving from Progressive Consumer Counseling Services, LLC.

MEDICAL RELEASE OF INFORMATION
AND
ASSIGNMENT OF BENEFITS

Please complete the form below if you agree for Progressive Counseling to contact your Primary Care Physician.

AUTHORIZATION TO DISCLOSE INFORMATION TO PRIMARY CARE PHYSICIAN

I understand that my records are protected under the applicable state law governing health care information that relates to mental health services and under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Records 42 CRF Part 2, and cannot be disclosed without my written consent unless otherwise provided for in state of federal regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. This release will automatically expire twelve months from the date signed.

SCHOOL AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby request and authorize the staff from PCCS, LLC. located at 5536 Old National Hwy. Suite 100, College Park, Georgia, College Park, Georgia, 30349 to enter my child's school to provide supportive services for the purpose of continuity of care in the community.

STATEMENT OF PARTICIPATION/ ORIENTATION OF SERVICES

CONSUMER/PARENT BEHAVIOR CONTRACT

CONSUMER

1. I will work on my treatment goals.
2. I will participate in ALL activities that pertain to my treatment plan.
3. I will reframe from ALL verbal and physical abuse towards staff and all
4. persons involved in my treatment.
5. I will respect the property of ALL staff and persons involved in my treatment. 

PARENT

1. I will actively work towards my child’s treatment plan/goals.
2. I will participate in ALL activities that pertain to my child’s treatment plan.
3. I will refrain from ALL verbal and physical abuse towards staff and all persons involved in my treatment.
4. I will respect the property of ALL staff and persons involved in my child’s treatment.
5. I will attend ALL groups that are offered to benefit my child’s treatment

SCHOOL CONSENT DISCLOSURE