***Some procedures/charges may not be paid by your insurance company. ***
Please be advised of the following charges, but are not limited to
Electronic Communications: $20.00 to $60.00
Phone Calls: $20.00 to $60.00
Initial Evaluations: $345.00 to $520.00
Follow Up Appointments: $135.00 to $405.00
Requests for paperwork/documents outside of appointments will have a $25.00 minimum
Late Cancellation & No-Show Policy
Please be advised that your appointment is set for a scheduled amount of time. If you are more than 10 minutes late you may reschedule but will be charged for the late cancellation charge. If you are late for your appointment and do not wish to reschedule, you will be seen for the amount of time left during that scheduled time.
• 1st Late Cancellation & No Show is given as a freebie.
Thereafter each one is subject to a full appointment charge.
Insured Assignment and Release of Information
I hereby authorize my insurance benefits to be paid directly to the provider. I realize that I am responsible to pay for any non-covered services and that I will be liable for a monthly finance charge of 1.0% or $5.00, whichever is greater, on balances over 60 days past due. I understand that I am also responsible to pay a late cancellation or no-show charge for failure to arrive at my appointment at the scheduled time or failure to provide 24 hours advance notice for canceled appointments. If not paid according to terms I understand that my account may be turned over to a collection agency, in which case I agree to pay all additional fees assessed in a collection of the debt. These fees include collection agency fees and attorney fees. I understand that there will be a $25.00 charge assessed on all returned checks.
I hereby authorize the release of pertinent medical information to the insurance company if necessary, to assist in claims processing as requested by the insurance company.
Please be advised I do not provide psychiatric evaluations that are court mandated or for use of court cases such as child custody cases. If I am subpoenaed and must appear in court or communicate with members of a legal team, I will bill an hourly rate and feesaccordingly if this interrupts my ability to care for other patients during that time.
Agreement between Divorced/Separated Parents
KC Family Hope Center’s policy regarding families who are in the process of parent separation/divorce, are separated/divorced or who are dealing with conflicts regarding co-parenting issues are stated below. If both parents understand and agree to this policy, it will allow me to serve you and your child most effectively and will minimize conflicts between parents regarding services. KC Family Hope Center prefers input from both parents. This may involve scheduling parent appointments to discuss communication and collaboration, in addition to child appointments. Both parents are very important in the lives of their children and children generally do best when they have active, healthy relationships with both parents. Children generally do best when parents treat each other with respect and cooperate with each other. Children suffer when there is ongoing, unresolved conflict between their parents. The success, or failure, of counseling children, often depends heavily on the support by both parents. I do not do assessments to assist parents, attorneys or the court in making decisions regarding Parenting Plans.
We (parents) fully understand and freely agree to these conditions regarding services for our child or children, and for ourselves regarding KC Family Hope Center.
Notice of Privacy Practices
This notice describes how medical information about you may be used, disclosed, and how you can get access to this information. *Please carefully review and retain for your records.
Understanding Your Health Record Information
Each time you visit or contact your mental health care provider, a record of this contract is made. This information often referred to as your “chart”, serves the following purposes: 1) a basis for planning your care and treatment, 2) a means of communication among the many health and mental health professionals who contribute to your care, 3) a legal document describing the care you received, 4) a means by which you or a third-party payer can verify that services billed were actually provided, 5) a source of data for education, research, and planning, 6) a source of information for public health officials charged with improving the health of the nation, and 7) a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve. Understanding what is in your record (chart) and how your mental health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access this information, and helps you to make more informed decisions when authorizing disclosure to others.
Your Health Information Rights
Although your mental health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right t:: 1) obtain a paper copy of the notice of privacy practices upon request, 2) request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522 (a), however, we are not required to agree to such a restriction, 3) receive confidential communications of your protected health information per 45 CFR164.522 (b), 4) inspect and copy your mental health record as provided for in 45 CFR 164.524, 5) amend your record as provided in 45 CFR 164.526, 6) receive an accounting of disclosures of your mental health information as provided in 45 CFR 164.528, 7) request communications of information by alternative means or at alternative locations, 8) revoke your authorization to use or disclose mental health information except to the extent that action has already been taken.
*Signature will be completed in office*
If the patient is over 13 years old they must sign below to consent to the receive treatment.