March 13, 2006



Consent for Psychological and Neuropsychological TestingThe general purpose of testing is to provide the individual(s) who referred you with information to assist in your diagnosis and treatment planning. ___Neuropsychological Testing:The goal of neuropsychological assessment is to determine if any changes have occurred in your cognitive abilities, such as attention, memory, language, problems solving, visuoperceptual abilities, or other thinking skills. This evaluation takes anywhere between 2 to 6 hours. Depending on the questions your referring providers have asked, information gathered during the neuropsychological assessment may be used to make diagnoses, determine your ability to make decisions, and/or make treatment recommendations. A neuropsychological examination includes an interview with yourself and possibly a separate interview with a friend or family member who is familiar with you. During these interviews, questions will be asked about your background and current medical and psychological symptoms. Additionally, during your exam, standardized tests and other techniques may be used, including, but not limited to, asking questions about your knowledge of certain topics, reading, drawing figures and shapes, learning word lists or stories, viewing printed material, manipulating objects, and describing psychological symptoms. Your task is to answer questions as accurately as you can; for example, when discussing your problems or concerns, do not minimize significant problems, but also do no exaggerate lesser concerns. Some examinees may be disposed to exaggerate symptoms as a way of making sure their problems are well documented; however, this, rather than helping your case, may make your tests more difficult to interpret. You are to give your best effort during the testing. This does not mean that you have to get every answer or problem correct, for no one ever does. Part of the examination will address the accuracy of your responses, as well as the degree of effort that you exert on the tests. It is important to be forthright and honest in your answers. Psychological Testing:An initial interview will take place to review background (examples, your school and job history) and symptoms. Tests may be administered to evaluate your academic, intellectual, personality, and emotional functioning. This evaluation usually takes between 1 to 5 hours, depending on the number of tests needed, and can be conducted in an office, clinic, or hospital.Foreseeable Risks, Discomforts, and Benefits:For some individuals, assessments can cause fatigue, frustration, and anxiousness. There are no other anticipated risks or discomforts associated with this evaluation. Communication Policy:Communication by phone or in-person are preferred when discussing your medical history and evaluation. Email is used only to arrange or modify appointments. Please do not send email related to the content of your appointments or evaluations, as email is not completely secure or confidential. If you choose to communicate by email, be aware that all emails are retained in the logs of internet service providers. If you feel the need to communicate about the content of your evaluation or appointment, then please call us. Please do not use SMS (mobile phone text messaging) or messaging on social networking sites such as Twitter, Facebook, or LinkedIn to make contact. These sites are not secure and the messages may not be read in a timely fashion.Confidentiality:Information in your file is strictly confidential and is subject to all the appropriate rules and laws. Your file will be kept in a locked office cabinet, and a copy of your report will routinely be sent to the referring person(s) and/or agency. Your case may also be discussed verbally with the referring person(s) and/or agency when appropriate. If applicable, insurance/workers’ compensation companies will often request a copy of your report in their evaluation of your insurance claim. If you are evaluated in a hospital, a summary of test results will be placed in your medical chart.Please be aware that there are other exceptions to the confidentiality rule. Laws require psychologists to:Report any disclosure or evidence of physical or sexual abuse of a child or an elderly or disabled person to authorities.Report the probability of the client inflicting imminent psychical harm upon himself/herself or others.Respond to subpoenas, court orders, or other legal proceedings or statures requiring disclosures.Please ask the doctor if you have any questions regarding limits of confidentiality.I have read the above and consent to testing by Clinical Neuropsychology of Texas, PLLC.Signature: _________________________________Date: ___________ ClientSignature: _________________________________Date: ___________ Legal Representative or GuardianSignature: _________________________________Date: ___________ WitnessSTATEMENT OF MEDICAL NECESSITYI understand that I, ________________________________, am undergoing an assessment which has been determined by my referring doctor to be clinically necessary as part of my medical care.Initial _____________I understand that my insurance company benefits will only provide reimbursement for services which are medically necessary.Initial _____________I understand that an assessment for non-medical purposes, such as for disability determination, suitability for employment, academic planning, involvement in a civil or criminal legal claim, or other non-medical purposes, is not a covered benefit and cannot be charged to my insurance.Initial _____________I understand that billing for an assessment that was requested for non-medical purposes to my insurance carrier may be fraudulent and may violate the terms of my contract with my insurance company, and that I may be billed for the full amount if I do not fully inform the psychologist or my insurance company about any non-medical purposes for my assessment.Initial _____________I understand that a clinical report will be available to my referring doctor within three weeks after my testing but that any other request for information for non-medical purposes, such as sending records to insurance companies or lawyers, filling out forms, consulting with attorneys, testifying, etc. will require additional prepaid out-of-pocket fees which will not be covered by my insurance company.Initial __________________________________________________________________________Patient/Guardian SignatureDate______________________________________________________________________________Patient NameFEES & INSURANCEFees for clinical evaluations range depending on the services required. A typical neuropsychological evaluation may range from $800-2500; however, the cost can be more or less depending on referral questions and other factors. Please ask your doctor, or contact our office, for further information about your specific circumstances. We are happy to answer any questions you may haveI understand that the office of Dr. Justin O’Rourke, as a courtesy to me, will attempt to verify my insurance benefits and file a reimbursement claim with my insurance carrier. I also understand that I, ____________________________________________, am fully responsible for payment for all services rendered by Dr. Justin O’Rourke.Signature: _________________________________Date: ___________ ClientSignature: _________________________________Date: ___________ Legal Representative or GuardianSignature: _________________________________Date: ___________ WitnessFinancial Information FormWe truly appreciate your choosing to come to our practice for neuropsychological services. As part of providing high-quality services, we need to be clear about our financial arrangements. If you have health insurance, it may pay for a part of the cost of your treatment here. To find out if this is so, my staff and I need the information requested below. We will explain any part of this form that that you do not understand.52006501778000If you have no health insurance coverage, or do not intend to use it, please check here and complete sections A, D, E, and F below. Today’s Date: _____________Referring Physician: __________________________________________PATIENT INFORMATION Patient’s name: _________________________ Birthdate: ___________ Soc. Sec. #: _____________Gender: Male__ Female__Marital Status: Single__ Married__ Divorced__ Widowed__ Separated__Address:_______________________________ City:_________________ State:______ Zip Code:_______Phone #: ___________ (If the patient is a dependent) Insured’s/policy holder’s name: ________________Driver’s License State & No:_____________________ Primary Care Physician:______________________Occupation:_______________ Employer:_____________________________ Work Phone:____________ Address of Employer:____________________________________________________________________SPOUSE’S INFORMATION (If applicable for insurance purposes)Spouse’s name:_____________________ Birthdate:_______ Soc. Sec. #:__________Occupation:_________________ Employer:_____________________________ Work Phone:_________Address of Employer:____________________________________________________________________ INSURANCE INFORMATION:Primary Insurance Information: Name of subscriber (if not the patient):_____________________________________________________Insurance Company:____________________________________________________________________Identification/policy #:_______________________ Group or enrollment #:________________________Insurance Company Phone:_______________________________________________________________Secondary Insurance Information (if applicable):Name of subscriber (if not the patient): _____________________________________________________Insurance Company: ____________________________________________________________________Identification/policy #:_______________________ Group or enrollment #:________________________Insurance Company Phone:_______________________________________________________________Do you or your spouse have any additional insurance coverage (Tricare, etc)?_______________________If yes, fill in empty section below:EMERGENCY CONTACTIf there is an emergency and you cannot contact me through the above numbers, I give permission for you to contact:Name:____________________________________ Relationship to Patient:________________________Phone #:__________________________________PAYMENTS:If you do not have insurance, how will you pay for services from this office: _____Cash _____Check _____Credit (American Express, Visa, Master Card, or Discover)Co-payments are due at the time services are rendered.AFFIRMATIONBY SIGNING BELOW:I give this office permission to release any information obtained during examinations or treatment of this patient that is necessary to support any insurance claims on this account and secure timely payments due to the assignee or myself.I authorize Dr. Justin O’Rourke to furnish information to my insurance carrier(s) concerning my or my dependents’ treatment and diagnosis rendered by Dr. Justin O’Rourke.I authorize and request my insurance company to pay directly to the practice of Dr. Justin O’Rourke all payments for psychological services rendered to myself or my dependents.I understand that I am responsible for all charges, regardless of insurance coverage.I hereby assign medical benefits, including those from government-sponsored programs and other health plans, to be paid to the neuropsychologist above. Medicare regulations may apply. A photocopy of this assignment is to be considered as good as the original._______________________________________________________Client’s (or parent/guardian’s) signature,DateIndicating agreement to all of the statements above__________________________________________Printed name ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download