By checking the "I Accept" box, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this agreement. By selecting "I Accept" you consent to be legally bound by this agreement's terms and conditions and all terms listed above.
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.
Interview and screeners conducted related to concerns and history to determine appropriateness of psychological testing. Test administration follows this appointment. Participation in the intake process does not guarantee that psychological testing services will be recommended by the provider.
Measures and activities are completed to assess the full scope of the individual and the presenting concern(s). Depending on the nature of the evaluation, collateral information may be obtained through completion of measures (i.e. caregivers, teachers) or interview. Duration of testing administration is dependent on the referral concern and need determined at intake. At times, additional testing may be recommended during the first testing session.
Scoring, interpretation of data, and writing of the psychological evaluation report. A full copy of the report is provided to the individual and/or family upon completion.
Meeting with a provider to review the psychological evaluation report, answer questions, and coordinate continued care. Unless otherwise discussed at the feedback session with your provider, all reports are final and further editing of the report will not be completed following the feedback session.
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:
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.
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:
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.
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