| Informed Consent/Office Policies |
INFORMED CONSENT AND OFFICE POLICIES (Rev. 6/08)
(1) Confidentiality
The nature and content of all sessions is strictly confidential and will not be released unless you give your permission in writing. There are some exceptions you need to know about: (1) Insurance reimbursement claim forms have to give code numbers for your diagnosis and service rendered. (2)Information about your account (not about your case) will be released if unpaid balances are turned over for collection. (3) If you make a claim in court that someone has caused you emotional harm or if you file a petition or response in connection with custody or visitation, your records can be released. (4) Other situations are rare and include: reasonable suspicion of abuse of a child or incapacitated adult; actual threat of physical violence against a clearly or reasonably identified victim; evidence that you pose a danger to yourself; substantial evidence of commission of a crime. If presented with a request about you for a security clearance, I must verify your permission, so please make sure I have your contact info after our work has ended if I am going to be contacted by an investigator.
(2)Scheduling and Cancellations
Your appointments are reserved for you. Sessions are 45-50 minutes unless longer sessions are arranged. There is no charge for cancellations made at least a full 24 hours (not just the day before, a full 24 hours) in advance. It is "OK" to cancel with less than 24 hours notice, but you will be charged for the session unless it is for an emergency. Pls note: Having to work does not count as an emergency. You will be charged if you miss a session without canceling, a “no show.” Cancellations must be made in person or through voice mail, NOT email. If you are late, you will still be charged for a full session. If Dr. Criswell is late (rare), you will get the full session. _____PLS INITIAL THIS POLICY
(3)Payment and Use of Insurance
Payment is required at each session by check or cash. Psychological evaluation reports must be paid for in advance. There is a $25 charge for a bounced check. Unpaid balances incur a late fee of $5 per week (up to 6 days, no late fee). Dr. Criswell uses a collection service on accounts past due over 30 days. If your account is sent for collection, your account balance will be increased by $25, plus the service charges you a fee of 33%. Many insurance policies will reimburse you for Dr. Criswell's services. For reimbursement, you pay Dr. Criswell directly, then submit your receipt for reimbursement. The terms of your policy are between you and your plan. Some services, such as writing of special letters and parent consultations about children who are not my patients, are not covered by insurance.
(4) Mutual Responsibility
My responsibility is to provide you a private space, dedicated time, and the best psychological services I can. Your responsibility is to show up and try your best. Many people make significant progress when they try.
I have read and agree to the above policies:
Signature(s): Date:
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Note: Telephone/IM sessions require additional consent; Minors have an additional consent. Forms provided at office.
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