Informed Consent and Guarantee of Payment Form

I. Informed Consent to Assessment
Houston Neuropsychology Associates, PLLC

Purpose of Assessment and Benefits: 
The purpose of the testing is to provide your doctor with a neuropsychological evaluation report to assist with diagnosis and treatment of your condition. The evaluation usually begins with a clinical interview to review your background, medical history, and current issues. Neuropsychological testing typically follows the interview, which provides information about your cognitive and emotional functioning. A trained technician typically conducts the testing, although the provider you will see is the only one responsible for interpreting the data and writing the evaluation report. Houston Neuropsychology Associates, PLLC (hereafter “HNA”) also serves as a training site for graduate students and postdoctoral residents in clinical neuropsychology. As such, portions of your evaluation might involve a graduate student or postdoctoral resident under the direct supervision of one of our licensed neuropsychologists.

Assessments will measure brain functioning using tests of information processing. The resulting data will clarify the scope of any problems that might exist and their possible causes, as well as provide guidance for appropriate treatment.

Foreseeable Risks or Discomforts: 
Neuropsychological evaluations may be time-intensive and involve mentally demanding tasks. For some individuals, this may contribute to mild fatigue, frustration, or anxiety. Our doctors and technicians understand this and are experienced in working with people from all types of backgrounds. We strive to treat our patients with the highest respect and to make each person feel as comfortable as possible.

Results of Assessments:
Once your appointment has ended and all data have been collected, it will take approximately five business days for your referring doctor to receive the results. It is customary for each patient to arrange to review the results of the assessment with his or her referring doctor. Doctors often refer patients for other tests (e.g., MRI, EEG, blood/urine screening, etc.) in addition to neuropsychological evaluation. As such, they usually have a more complete medical record and may provide an integrated diagnostic and treatment plan. However, if requested, one of our doctors will be happy to review the neuropsychological evaluation results with you.

Testing Fees and Payment Policy: 
Appointments typically require 2 to 4 hours. Fees usually range from $975 to $2,800. However, depending upon the circumstances and specific nature of the case, the number of hours and fees may be greater or less than the stated range. The patient and/or his or her designated representative (hereafter “Responsible Party”) understand(s) that HNA will process the data to complete insurance claim(s), but only as a courtesy to the Responsible Party. It is understood and agreed that the Responsible Party is responsible for all monies due and owed for services rendered by HNA in the event that insurance does not pay for these services. The Responsible Party also understands and acknowledges that he/she is personally responsible to pay HNA in full for services that his/her health insurer will not cover due to non-payment of health insurance premiums. Moreover, the Responsible Party is responsible for any co-insurance payment and any remaining deductible at the time of service unless other arrangements are made.

Test Security and Cell Phone Usage: 
To maintain test security, no recording is permitted in our office, including photographs, audio, or video recording. Cell phone usage (including voice calls, texts, etc.) is not permitted once an appointment begins. If you have an urgent situation, please inform the doctor in advance and a break will be arranged during the appointment for you to check your messages.

Information in your medical record is strictly confidential. Your medical record will be kept in our office and a copy will be sent to the referring healthcare provider who will maintain it in his/her files. Insurance companies also frequently request a copy of your record to be utilized in evaluating your insurance claim. Please be aware that there are other exceptions to the confidentiality rule. The law requires psychologists to (1) report any disclosure or evidence of physical or sexual abuse of a child to authorities; (2) report any abuse of an elderly or disabled person to authorities; (3) report the probability of imminent physical injury to the patient or others; and (4) respond to subpoenas, court orders, or other legal proceedings or statutes requiring disclosures.

It is also our policy for every patient to be offered a copy of our Notice of Information Practices, and to sign a statement for his or her medical record verifying the opportunity to review our policy.

II. Guarantee of Payment and Assignment of Insurance Benefits

The undersigned guarantor and/or patient (hereafter the “Responsible Party”) agree(s) to pay Houston Neuropsychology Associates, PLLC (hereafter “HNA”) all fees for services rendered to the Responsible Party. HNA will process the forms needed to complete insurance claim(s), but only as a courtesy to the Responsible Party. The Responsible Party authorizes HNA to release any and all medical information necessary to complete insurance claim(s) and collect any fees under the insurance contract. The Responsible Party also authorizes use of this form on all insurance claim submissions.

The Responsible Party bears ultimate responsibility for completing and finalizing any insurance claims. In the event that the insurance carrier withdraws any fees received by HNA, the Responsible Party will be responsible for those fees. In the event that fee collection is turned over to a collection agency, the Responsible Party hereby agrees to pay all costs of collection billing.

The Responsible Party acknowledges that our services often require more than one day’s time. Testing is usually performed on a single day but scoring, analysis, and report writing may occur on one or more days after the testing appointment. Due to this fact and insurance company practices, coinsurance payment may be required for more than one day of service (including a date when the patient was not in our office).

In the event that the Responsible Party’s insurance does not cover our services (or any portion thereof), HNA will work with the Responsible Party regarding payment (e.g., setting up a payment plan). We reserve the right to charge reasonable late fees in the event that full payment is not made within 30 days.

We will charge a $125 fee if you cancel your appointment with notice of less than 24 hours or if you do not appear for it. We will ask that this fee be paid before scheduling any future appointments at our practice. This fee will not be covered by your insurance and will be due from you directly. The nonrefundable late cancellation fee for full-day appointments, such as testing for possible academic accommodations, independent medical evaluations (IMEs), and related services is $1,200.

Our office will file the Responsible Party’s initial claim(s) and provide documentation necessary for insurance reimbursement. We do not, however, guarantee that each service will be covered, or the percentage that will be covered.

Therefore, it is understood and agreed that the Responsible Party is responsible for all fees for services rendered by HNA in the event that insurance does not pay for these services. Furthermore, the Responsible Party is responsible for all fees in the event that insurance deems the services to be a non-covered benefit, and/or not medically necessary.

If you have any questions, please speak with our office manager or one of our doctors. Your electronic signature indicates that you have read the above and agree to the terms contained therein. These agreements are irrevocable.

Please complete the form below and click the Submit button when finished. This form is your electronic signature.