LORA HOFFSTETTER & COUNSELING ASSOCIATES, LLC
CONSENT FOR TREATMENT - PROFESSIONAL SERVICES AGREEMENT
RELATIONSHIP
I understand that the effectiveness of psychotherapy depends on the efforts of the client as well as the practitioner, and I promise to make my best effort to comply with those procedures. I understand that I am entering into a therapeutic relationship with a licensed professional. I understand that this professional may recommend that I complete other forms of treatment; i.e.; psychological testing, psychiatric evaluation, or clinical homework. I understand that I am fully responsible for the outcome of my treatment, and that results may vary based on adherence to such recommendations. I further understand thatLora Hoffstetter & Counseling Associates, LLC (LHC)is making no guarantees about the outcome of treatment, as the field of psychotherapyor psychiatry or hypnotherapy is based on individual response.
CANCELLATION POLICY
I understand that regular attendance will provide the maximum benefits but that I am free to discontinue treatment at any time. If I decide to do so, I will notify Clinician at least two weeks in advance so that effective planning for my continued care can be implemented. I will notify Clinician at least 24 hours in advance if I will be unable to attend any session. If I fail to make such notification, I will be charged a $75.00 cancellation fee, which will not be reimbursed by my insurance company, and I will be solely responsible for these charges. I understand that I can call Lora Hoffstetter & Counseling Associates, LLC 24 hours/7 days a week, and leave a message to cancel an appointment. If I have three (or more) last minute cancellation or no show appointments, my therapist/psychiatrist may decide to discontinue our sessions, and refer me to a community mental health agency.
CONFIDENTIALITY POLICY
I further understand that conversations with the Clinician will almost always be confidential. I understand that a mental health professional, by law, must report actual or suspected child abuse or neglect or elder abuse or neglect to the appropriate authorities. In addition, the Clinician has the legal responsibility to protect anyone that I may threaten with violence, harmful or dangerous actions (including those to myself) and may break confidentiality of our communication if such a situation arises. I understand that the mental health professional will make reasonable efforts to resolve these situations before breaking confidentiality.
APPOINTMENTS FOR MINORS
At the first appointment for a minor, at least one biological parentmust be present and bring a photo ID. LHC will need to match the signature on ID with signatures on paperwork. (LHC) is ethically bound to verify a minors’ biological parents/guardian.
ACADEMIC/ DIAGNOSTICTESTING
Testing is not a covered service. The fee schedule is $130.00 for the assessment, and then $110.00 for testing per hour thereafter. The number of sessions it takes to complete testing is up to the therapist who is administering the testing and will be determined at the time of the initial assessment. I can pay the entire fee up front or pay at each appointment. I understand that there is no payment plan for these services.
If I would like to utilize any of the testing services there will be a onetime testing fee of $60.00 per person at the beginnining of my testing experience. This fee is to cover the testing materials. I will be charged $130.00 due the first day of the first assessment. If a report is needed, it will be ready approximately 2 weeks after my final results session with the therapist. The report is free of charge and is included in the price of the testing. If a longer, more in depth report is needed there will be a charge of $150.00. I am responsible for letting the therapist know where the report needs to be sent to. If a personality test is required there will be an extra charge of $75.00.
Additional time spent scoring, discussing results or concerns with other providers, school personnel, probation officer, etc, will be charged at the prorated fee of $110.00 per hour, based upon the therapist’s discretion.
FINANCIAL RESPONSIBILITES
I understand that I am financially responsible for the cost of the psychological services or any portion of the fees not reimbursed by my health insurance. If my mental health care is provided under the terms and conditions of a managed health care program, which the Clinician is contracted, my financial responsibility may be limited to the terms of the contract. If my balance is over $50.00 I must make payment arrangements with the office staff prior to future appointments being made. Failure to pay these bills may result in collection procedures (including court proceedings) being taken against me by LHC or a collection agency contracted by same to collect these bills. I also understand that I will be responsible for any additional charges incurred through the use of a collection agency contracted by LHC to collect these bills. I also understand that I will be responsible for fees incurred through the use of a collection agency or the filing of a court action including attorney and filing costs. I further understand that professional services will be rendered to me by Lora Hoffstetter & Counseling Associates, LLC.
A flat fee of $20.00 will be charged for any forms that a client asks the clinician to complete, such as SSA, Disability papers, FMLA or leave of absence form. Additional fees may be billed for extra services, including treatment or case summaries and reports, court related proceedings, and phone calls lasting more than 10 minutes (including coordination of care with other professionals and phone calls to clients directly).INSURANCE DOES NOT PAY FOR EXTRA TIME SPENT IN BETWEEN SESSIONS. AN HOURLY FEE WILL BE PRORATED BASED UPON THE SERVICES RENDERED; Psychiatrist fee is $250.00/hr; psychotherapist fee (LISW, LPCC, LSW, LPC, MFT) is $110.00. If you or an isorganization on your behalf is requesting your medical records, we can do so with your written consent. Medical records fee is $1.00 for pages 1-10, .50 for pages 11-50, and .25 for pages 51+. It is the client’s responsibility to pay for extra services.
**I request that LHC submit my bill to the insurance company which I have listed on the Client Intake Form, and I grant permission to the Clinician and the Billing Service to release such confidential information as is necessary to obtain payment from the insurance company. In the event that my insurance company fails to observe Ohio prompt payment standards or otherwise fails to adhere to appropriate business standards, I grant permission to share information related to my insurance with the Ohio Department of Insurance.**
Releasing Clients’ Records
Access requests for records must be in writing and must be acted on within 30days. Access can be denied if it might harm the client. If your provider comes to believe that allowing client access to his or her PHI is likely to endanger the life, safety, or health of the client or someone else, provider can deny access. Provider can withhold records in non-emergency situations if client has balance on account.
COPAYMENT POLICY
As of 1/1/2010 it will be necessary for all clients to pay their co-pay at the time of their visit. If you are unable to make your co-pay at the time of your scheduled visit please reschedule more than 24 hours in advance to avoid a cancellation fee. If your adolescent children are coming to visit us, please be sure they are prepared.
ASSIGNMENT & RELEASE: I HEREBY ASSIGN MY INSURANCE BENEFITS TO BE PAID DIRECTLY TOLORA HOFFSTETTER & COUNSELING ASSOCIATES, LLC. I AM FINANCIALLY RESPONSIBLE FOR NONCOVERED SERVICES AND DEDUCTIBLES. I ALSO AUTHORIZELORA HOFFSTETTER AND COUNSELING ASSOCIATES, LLC TO RELEASE ANY INFORMATION REQUESTED TO MY INSURANCE COMPANY, MANAGED CARE COMPANY, THIRD PARTY ADMINISTRATOR OR ANY OTHER PERSON OR ORGANIZATION NECESSARY IN THE SUBMISSION, PROCESSING AND APPROVAL OF CLAIMS. MY SIGNATURE BELOW INDICATES THAT I HAVE AGREED TO ALL THE ABOVE TERMS OF THIS CONSENT FOR TREATMENT/PROFESSIONAL SERVICES.
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CLINICIAN DATE
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CLIENT'S SIGNATURE OR PARENT/GUARDIAN/REPRESENTATIVE DATE
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WITNESS DATE
** SIGNATURE REQUIRED ON BACKSIDE **