Agreement to Pay
If the patient is a minor, I understand that I have a right to the information my child shares with Dr. Clark and I will use this and any information shared for the child's best interests.
If, at any time, I am dissatisfied with this therapy, I will fully discuss my views, reasons and plans with Dr. Clark (and if the client is a minor, with the client named above) prior to terminating therapy.
I agree that this financial relationship will continue in effect with Dr. Clark as long as she provides services or until I inform her in person, by telephone or by certified mail, that I wish to end it. I agree to pay for services rendered to myself or my child/ward up until the time I terminate the relationship.
I understand that I am responsible for charges for services provided by Dr. Clark to me or my child/ward, although other persons or insurance companies may make payments on my account.
CANCELLATION OR NO-SHOW POLICY
I understand that I must cancel an appointment 24 hours in advance to avoid a cancellation fee. I will be charged half of my usual session fee if I cancel between 24 and 2 hours prior to my appointment. I will be charged the full session fee if I cancel less than 2 hours prior to the session or if I fail to show up at all. The session fee is either the amount I self pay or the amount that the insurance company pays including my co-pay.
I agree to provide my credit card information at the time of intake and for my credit card to be charged the appropriate fee as indicated above in the event of a cancellation or no-show.
Consent to Treatment
I have reviewed and fully understand the information provided on the web site in the "Notice Of Privacy Practices" regarding my rights and responsibilities as Dr. Clark's client.
I have reviewed and fully understand the information provided on the web site in the "Notice Of Privacy Practices" regarding the limits of confidentiality of my records.
I have reviewed and fully understand the information provided on the web site or during consultation with Dr. Clark regarding the cost of services. I understand and agree that I am responsible for all fees and co-payments, payable each time I come to treatment. I am aware that I may terminate my treatment at any time without consequence, but that I will still be responsible for payment for the services I had received. I am aware that if I have not paid for services received, my treatment may be discontinued by Dr. Clark.
I am aware that the development and review of my progress, or of a Treatment Plan, is in my best interest and may be required by governmental, funding, accrediting or other agencies and I agree to actively participate in this process.
I am aware that the practice of psychotherapy or counseling is not an exact science and so predictions of the effects are not precise or guaranteed. I acknowledge that no guarantees have been made to me regarding the results of treatment or procedures provided by Dr. Clark.
I understand that I may address any concerns or grievances with Dr. Clark or any other representative of my insurance provider at any time. I understand that I may also contact the licensing board which regulates Dr. Clark's professional practice.
I am aware that Dr. Carol L. Clark, PA is not responsible for any personal property or valuables I bring into the facilities. I acknowledge that if I, or anyone else for whom I am legally responsible, deliberately causes damage or steals any property of this office, I will be held financially responsible for its replacement.
I am aware that any cancellations of appointments must be made more than 24 hours in advance of the appointment and if I do not cancel or do not show up I will be charged for that appointment.
Notice of Privacy Practices
Dr. Carol L. Clark may use and disclose protected health information, including but not limited to name, address, health history, symptoms, examination and test results, diagnosis and treatment, for payment from third party payors such as health insurance companies or health care operations. I understand that I must consent to this use and disclosure in order to enroll in or receive services through Dr. Clark unless I am privately paying for my treatment.
I understand that I have been provided with a copy of the document entitled Notice of Privacy Practices that provides a complete description of potential uses and disclosure of my protected health information. I understand that I have the right to review the Notice of Privacy Practices, which is provided on the website, prior to signing the consent.
I understand that Dr. Clark reserves the right to change her privacy practices and will provide a copy of any revised material at my next appointment or will mail one to me upon my request to the address that I have provided. The Notice of Privacy Practices is also posted in the office waiting room.
I understand that I have the right to request that Dr. Clark restricts how protected health information is used or disclosed to carry out treatment, payment or health care operations. I further understand that Dr. Clark is not required to grant any request to restrict the use or disclosure of information. If, however, Dr. Clark agrees to the requested restriction, the restriction is binding on her.
I agree that I have the right to revoke this Consent in writing, except to the extent that Dr. Clark has already relied upon it. I understand that if I do revoke this Consent, Dr. Clark may choose to discontinue providing me with healthcare treatment and services.
