Psychological testing is a specialized service that uses standardized assessment measures and procedures to gather data to inform diagnosis and treatment direction. Psychological testing services are provided by a team of qualified behavioral health providers. This may include a licensed psychologist, a doctoral psychology fellow and/or a psychometrist. All providers have the appropriate training and supervision to provide services. All services are supervised by licensed psychologists.

The primary benefits of psychological testing are diagnostic clarification, appropriate treatment recommendations, and written documentation to support facilitation of services. Although most clients have a positive experience during the evaluation process, there are some risks. The person being evaluated may experience emotional discomfort. It is possible that the evaluation will not answer all of your questions, and further evaluation may be recommended. While the assessment and treatment recommendations are based on best practices and the expertise of your provider, you or others may not agree with the conclusions. It is your decision whether to follow the recommendations.

You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in your Clinical Record. It includes information about your reasons for seeking testing, a description of the ways in which your problem impacts your life, your diagnosis, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself, you may examine and/or receive a copy of your Clinical Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence or have them forwarded to another mental health professional to discuss the contents.

Upon completion of the evaluation, your psychological testing report may be delivered to you via email. While we take precautions to protect your privacy, it is important to understand that email communication carries inherent risks, including the potential for unauthorized access, misdelivery, or interception. By consenting to receive your report via email, you acknowledge and accept these risks. You reserve the right to request your report in another format (e.g., printed copy).

Insurance Coverage: We accept most plans from the following insurance companies: Medicare, Aetna, Excellus, Blue Cross Blue Shield (BCBS), Lifetime Benefit Solutions, MVP, Highmark, Independent Health, and Anthem. We do not accept United Healthcare, Fidelis, or straight Medicaid. However, we do accept some Medicaid Managed Care Plans (e.g., Blue Choice Option) sponsored by the insurance companies listed above.

While intake and feedback appointments are generally covered, the testing portion—which includes both face-to-face and extensive non-face-to-face work—is almost never covered, despite often initially indicating to clients that it is. As a result, we charge a flat, out-of-pocket rate for each comprehensive evaluation. This testing fee includes all in-person testing time, review of relevant records, approved communication with collateral sources, scoring and interpretation of results, preparation of a detailed written report, and development of tailored recommendations and referrals to support treatment planning and educational accommodations.

You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of financial hardship, I may be willing to negotiate a payment installment plan.

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court, which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient's treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.

Your signature on this agreement indicates your understanding that you are responsible for full payment of fees for my services. Any fees for services provided not covered by the insurance company will be your responsibility. You are responsible for paying applicable co-pays, co-insurance amounts, or deductibles at the time of service.

Due to the significant time and preparation involved in psychological testing appointments, we require at least 24 hours' notice for any cancellations or rescheduling requests. Appointments canceled with less than 24 hours' notice, or missed without prior notice ("no-shows"), will be subject to a $75 fee. We understand that unexpected situations can arise, and we are happy to work with you to reschedule when adequate notice is provided. Prompt communication allows us to better serve all clients and make efficient use of clinician time.

The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advanced consent. Your signature on this Agreement provides consent for those activities, as follows:

• I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential.
• Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
• If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection.

There are some situations in which I am legally obligated to take action, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient's treatment. These situations are rare in my practice.

• If I have reason to suspect that a child is abused or neglected, the law requires that I file a report with the appropriate governmental agency, usually the Department of Social Services. Once such a report is filed, I may be required to provide additional information.
• If I have reason to suspect that an incapacitated adult or elderly person is abused, neglected, or exploited, the law requires that I report to the Department of Welfare or Social Services. Once such a report is filed, I may be required to provide additional information.
• If a patient communicates a specific threat of immediate serious physical harm to an identifiable victim, and I believe he/she has the intent and ability to carry out the threat, I am required to take protective actions. These actions may include notifying the potential victim or his/her guardian, contacting the police, or seeking hospitalization for the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.

Psychological testing takes place in person; however, telehealth may be used for intake or feedback sessions. Your signature on this document represents your understanding of the following with respect to telehealth:

• I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
• I understand I must be located in NY at the time of my telehealth session and provide my address to be used in case of emergencies.
• I understand that there are risks, benefits, and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
• I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
• I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth.
• I understand that during a telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, we may have to reschedule.
• I understand that my provider may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

Your signature acknowledges that you have received and have been given an opportunity to read a copy of privacy practices for Penfield Psychiatry/Finger Lakes Psychiatry, which can be found here: https://www.penfieldpsych.com/policies/privacy-policy. If you have any questions regarding the Notice or of your privacy rights, you can contact Penfield Psychiatry.

I HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. I ACKNOWLEDGE THAT I HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. I CONFIRM THAT I HAVE BEEN GIVEN THE OPPORTUNITY TO ASK QUESTIONS ABOUT THE ABOVE POLICIES AND MAY ASK ADDITIONAL QUESTIONS AT ANY TIME IN THE FUTURE. I CONSENT TO PARTICIPATE IN PSYCHOLOGICAL SERVICES OFFERED BY PENFIELD PSYCHIATRY.