UHC Psychological Testing Consent Form

UHC Psychological Testing Consent Form
PSYCHOLOGICAL TESTING PRIVATE PAY CONSENT FORM
Morrison Clinic is in network with several different insurance carriers and unfortunately United Health Care/Optum have determined that they will not pay for Morrison Clinic psychological testing.

Psychological testing is a very important part of your treatment at the Morrison Clinic and it is recommended by the American Psychiatric Association to diagnosis psychiatric illnesses and to monitor effect of treatment interventions. Psychological testing allows your clinician to measure you symptoms in an objective manner to more effecitvely monitor your response to treatment. By repeating these tests prior to each medical appointment your clinician is not only given concrete data to quantify the severity of your symptoms but also is able to track seasonal variations in your illness.

Since poor emotional health correlates with poor physical health, psychological testing to monitor patient outcomes can actually lower your health care costs. By quantifying the severity of your symptoms and adjusting your medication to the optimal dose both you should see improvements in your emotional health , your physical health, and your ability to function well at work and home. Monitoring treatment response with psychological testing is an evidence based treatment approach which has been associated with improved patient outcomes. , Poor management of psychiatric symptoms has been associated with the additional health care costs incurred by persons with mental health diagnoses. In the United States in 2012, these additional costs among commercially insured, Medicaid, and Medicare beneficiaries was estimated to be $293 billion—a figure that is 273% higher than the health care cost for patients without a psychiatric diagnoses.

While it is disappointing that your insurance company does not reimburse for psychological testing, we do feel it is in the patient's best interest to pay for this service out of pocket so we have decided to offer you a significant discount for psychological testing.
- Psychological testing done prior to each medical appointment utilizes the code 96136 since it includes more than 2 tests.
- If additional tests are needed the day of your appointment than the code used for one test is 96146 and the code for 2 tests or more is 96136.
Code

Charge Discount Patient Responsibility
96136

$82.34 $52.34 $30
96146 $30 $15 $15

On January 1st of each year beginning in the year 2021 the patient responsibility will increase by 5% to offset inflation.
Name of Cardholder/Guarantor*
First NameLast Name
Patient Name if Cardholder is not the patient
First NameLast Name
Guarantor Relationship to patient
Date*
MonthDayYear
Date
It is important that you keep a copy of this agreement for future reference. You can print a copy by clicking the link at the bottom of the page. Please enter your email below so a copy of this form can also be e-mailed to you: *
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CARDHOLDER SIGNATURE OF AGREEMENT THAT YOU ARE RESPONSIBLE FOR THE COST OF PSYCHOLOGICAL TESTING SINCE PATIENT'S INSURANCE DOES NOT COVER IT: Your signature below attests that you read this agreement and understand that the patient's insurance does not cover psychological testing and you understand Morrison Clinic's psychological testing private pay policy. You agree to be responsible for any balance present on the patient's account and will pay in full for all services rendered.
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CARDHOLDER SIGNATURE FOR AUTHORIZATION TO CHARGE YOUR CREDIT CARD: Your signature below authorizes Morrison Clinic to keep your signature on file for your lifetime and to charge your credit card for patient's psychological testing.
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CARDHOLDER SIGNATURE OF AGREEMENT TO NOT DISPUTE CREDIT CARD CHARGES FOR PSYCHOLOGICAL TESTING: Your signature below attests that you will not contest charges to your credit card for psychological testing and you acknowledge that if payment is declined by a credit card payer a $25 fee will be applied to the patient's account. Should you dispute a credit card payment you agree to pay an additional $30 processing fee for each disputed charge in addition to the declined credit card fee, attorney fees incurred in disputing the chargeback, and any money owed.
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Should be Empty:

Code	Charge	Discount	Patient Responsibility
96136	$82.34	$52.34	$30
96146	$30	$15	$15

UHC Psychological Testing Consent Form

PSYCHOLOGICAL TESTING PRIVATE PAY CONSENT FORM