Please read the following (I & II) and sign electronically below.

I. Informed Consent to Assessment
Houston Neuropsychology Group, PLLC

Welcome to our office. We look forward to working with you and your referring doctor in addressing your problem.

Testing Fees:
Testing typically requires 3 to 5 hours over a 1-2 day period. Fees usually range from $975 to $2,000. However, depending upon the circumstances and specific nature of the testing, the number of hours and the fees may be greater or less than the stated range.

Payment Policy:
The patient and/or his or her designated representative (hereafter “Responsible Party”) understand(s) that Houston Neuropsychology Group, PLLC will process the paperwork 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 Houston Neuropsychology Group, PLLC in the event that insurance does not pay for these services. The Responsible Party is responsible for any co-insurance payment and any remaining deductible at the time of service unless other arrangements are made.

Nature and Purpose of Assessment:
The purpose of the testing is to provide your referring doctor with a  neuropsychological or psychological report to assist with diagnosis and treatment of your condition. The testing will consist of an initial interview to review your background and symptoms to be followed by tests, which provide information about your memory, attention, language, visuospatial, reasoning, motor, and academic skills, as well as personality and emotional functioning.

Foreseeable Risks, Discomforts, and Benefits:
For some individuals, the testing process may cause fatigue, frustration, and/or anxiety. Our doctors and technicians are experienced in working with people of various ages and from all types of backgrounds. We understand that some people may feel nervous about getting tested. We strive to treat our patients with the highest respect and to make each person feel as comfortable as possible. Assessments will measure brain functions 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.

Results of Assessments:
Once your appointment has ended and all data have been collected, it will take approximately 5-10 business days for your referring doctor to receive the results. Each patient should arrange to review the results of the assessment with his or her referring doctor. Houston Neuropsychology Group, PLLC functions as an outside consultant to referring health care professionals in a manner similar to a diagnostic laboratory. Accordingly, our office does not typically communicate test results to patients. The referring doctor usually has a more complete medical record on each patient, and should be the primary point of contact for any questions about test results.

Confidentiality:
Information in your file is strictly confidential. Your original file with raw data will be kept in our office and a copy of your report will routinely be sent to the referring doctor and/or hospital that will maintain this information in their own files. Insurance companies frequently request a copy of your report or office notes 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.
4. Respond to subpoenas, court orders, or other legal proceedings or statues requiring disclosures.

In legal cases, confidentiality cannot be guaranteed. Once a report is released to an attorney or court, such records often become “public records.” Please ask the doctor if you have any questions regarding the limits of confidentiality.

It is also our policy for every patient to be offered a printed 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
Houston Neuropsychology Group, PLLC

The undersigned guarantor and/or patient (hereafter the “Responsible Party”) agrees to pay Houston Neuropsychology Group, PLLC all fees for services rendered to the Responsible Party. Houston Neuropsychology Group, PLLC will process the forms needed to complete insurance claim(s), but only as a courtesy to the Responsible Party. The Responsible Party authorizes Houston Neuropsychology Group, PLLC 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 Houston Neuropsychology Group, PLLC, 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.

In the event that the Responsible Party’s insurance does not cover our services (or any portion thereof), Houston Neuropsychology Group, PLLC 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.

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 Houston Neuropsychology Group, PLLC 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 signature below indicates that you have read the above and agree to the terms contained therein. These agreements are irrevocable.