Welcome to Solutions!
CONFIDENTIALITY: All counseling services are considered
confidential. This confidentiality extends to the clinical supervision of your
treatment. Information cannot be released to anyone outside this practice
without your written permission, except as mandated by law (such as child
abuse), or to prevent a clear and present danger to yourself and/or another.
If more than one member of the family is receiving counseling services, each
family member must agree to sign such permission. The signature of a parent or
guardian is required for children who are under the age of eighteen (18).
The signatures of both the patient and parent/guardian are required if the
patient is 14-17 years of age, I understand that information relating to
my treatment at Solutions, i.e. psychotherapy notes, may be communicated to my
primary care physician, my insurance/behavioral health company, EAP and my
referral source. If I received behavioral health care in the past I will
contact that treatment provider and have that information forwarded to
Solutions Counseling. I am aware that Health Insurance Portability and
Accountability Act (HIPAA) information regarding the privacy of my health
information has been made available to me.
APPOINTMENTS/CANCELLATIONS: An extended period of professional time has been set aside for you. It is very important that you arrive at your specified time so that we can utilize as much of your scheduled time as possible. Therapy sessions are generally 45 minutes long. Cancellations with less than 24 hours notice or missed appointments are your responsibility and cannot be billed to your insurance company. You will be billed a late cancellation fee of $50.00 for an appointment canceled or broken if less than 24 hours notice is given.
ANSWERING SERVICE: Our business office hours are Monday through Friday 9 a.m. to 5 p.m. If our office is closed and a personal emergency or crisis arises, we have an answering service available that will immediately respond to your call.
PAYMENT AND INSURANCE: Payment for services must be made at the time of each visit. Because of the differences in insurance plans, we suggest that you contact your insurance carrier to determine what coverage you have, and be sure to specify "outpatient psychotherapy". We will submit billing to your insurance carrier, but you are ultimately responsible for payment should your insurance company deny any claim. There is also a $40 charge for returned checks. Please be advised that report preparation, completion of disability forms and court related costs are not covered benefits; therefore, you would be responsible for any fees incurred for these services. Nonpayment of a balance on an account may result in the use of a collection agency or possible legal action. Any accompanying fees will also be your responsibility
Please complete the following: (PAYMENT OPTION)
I authorize Solutions Counseling & Consultation Services to keep my signature
on file and to charge my VISA/MASTERCARD account for any unpaid charges.
_________________________________________________
_______________________
Patient/guardian Signature
Date
VISA MASTERCARD _______________________________
_______________________
(Circle One)
Card Account Number
Expiration Date
I understand that I am responsible for all charges incurred by me. If my
child is from a separated/divorced family where legal custody is shared, I
agree to inform the other parent about this treatment. I understand that
my signature gives permission for treatment.
_________________________________________________
_______________________
Patient signature (14 and older)
Date
_________________________________________________
_______________________
Parent/guardian signature (if under 18)
Date
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A Multidisciplinary Private Professional Practice rev. 4/03 |
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Direct all correspondence to: |
WILLIAM G.
LEE, Ph.D. |
Brookside Professional Park |