I understand that I am responsible for any unpaid balance on my account and for charges for any missed appointments not cancelled within 24 hours.
Look over each condition and fill in those that apply
Drug Use Checklist
Look over each drug and fill in those that apply
List of Operations Over Course of Lifetime
The information above and on the previous pages are true to the best of the undersigned’s memory
Our practice is dedicated to maintaining the privacy of your personal health information as part of providing professional care. We also are required by law to keep your information private. These laws are complicated, but we must give you this important information. This pamphlet is a shorter version of the full, legally required NPP and you may have a copy of this to read and refer to it for more information. However, we can’t cover all possible situations so please talk to our Office Manager (see the end of this pamphlet) about any questions or problems.
We will use the information about your health, which we get from you or others mainly to provide you with treatment, to arrange payment for our services, and for some other business activities, which are called, in the law, health care operations. After you have read this NNP, we will ask you to sign a consent form to let us use and share your information. If you do not consent and sign this form,
we cannot treat you.
If you or we want to use or disclose (send, share release) your information for any other purposes, we will discuss this with you and ask you to sign an authorization form to allow this.
Of course we will keep your health information private, but there are some times
when the laws require us to use or share it. For example:
There are some other situations like these but which don’t happen very often. They are described in the longer version of the NPP.
If you have any questions regarding this notice or our health information privacy policies, please contact the Psychologist who is Dr. Wade H. Silverman and can be reached by phone at 305-669-3605.
The effective date of this notice is April 30, 2003.
Also, you may have other rights, which are granted to you by the laws of our state and these may be the same or different from the rights described above. We will be happy to discuss these situations with you now or as they arise.
I hereby certify and I understand the above and have been informed of policies and procedures regarding appointments and fees. Furthermore, I authorize treatment by Wade H. Silverman
Thank you for choosing me as your mental health care provider. I am committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of the Financial Policy, which you are required to read and sign prior to any treatment.
All patients must complete our Information and Insurance form before seeing the doctor.
- FULL PAYMENT IS DUE AT THE TIME OF SERVICE -
- WE ACCEPT CASH, CHECKS, OR CREDIT CARDS -
Appointments are scheduled for the same day and time each week unless altered by the doctor or yourself in advance.
I understand that payment is expected upon receipt of service. I agree to pay 1.5% per month if I am delinquent in my account and have to be re-billed. I also understand that should any action need to be taken to collect for professional services rendered, the professional provider shall be entitled to recover any attorney fees.
We cannot bill your insurance company unless you give us your insurance information. We are not a party to that contract. We require that you be pre-approved and we will do so as a courtesy. Whatever portion your insurance does not pay will automatically be transferred to your bill. Please be aware that some, and perhaps all, of the services provided may not be considered reasonable and necessary under your insurance plan.
Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary
determination of usual and customary rates.
Adult patients are responsible for full payment at time of service.
The adult accompanying a minor and the parents (or guardians of the minor) are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-paid by credit card or cash.
We require, at least 24 hours in advance, to cancel an appointment. Any calls made after 5:00pm or on Saturdays and Sundays to cancel appointments will not be accepted .Thus, if your appointed is after five o’clock, you must call before five o’clock on the previous day. If your appointment is on a Monday, you must call before 5:00pm on the previous Friday. Please help us serve you better by keeping scheduled appointments.
Unless it is an emergency, all therapeutic contacts take place in the office. Should you request therapeutic interventions on the telephone you will be charged $225 per hour prorated in .10 hours. Most insurance companies will not reimburse telephone time.
Thank you for understanding our Financial Policy. Please let us know if you have questions or concerns. I have read the Financial Policy. I understand and agree to this Financial Policy:
Marital and Family Psychotherapy
Beck Depression Inventory (BDI)
Beck Anxiety Inventory (BAI)
Child Abuse Potential Inventory (CAP-VI)
Detailed Assessment Post-traumatic Stress (DAPS)
Mini Mental Status Exam (MMSE)
Minnesota Multiphasic Personality Inventory (MMPI-2)
Million Clinical Multiaxial Inventory (MCMI-III)
NEO Personality Inventory (NEO-PI-3)
Wechsler Adult Intelligence Scale (WAIS-III)
Preparation of Report
Cancellations must be made 24 hours in advance. Patients will be charged for the session if they do not call and cancel