Adult Consent to Treatment Form
Consent to Treatment Form
Private insurance and cash-paying clients may pay for services with cash, check, debit or credit card (VISA, Mastercard, Discover, American Express). $80 per 60-minute hour is the normal fee for services and a negotiated fee between provider and client may be possible after the first visit. There are no out-of-pocket fees for services for Medicaid clients. If you have private insurance, please call them to find out what your out-of-network, outpatient psychotherapy benefits are. Fees for services are due at the time the service is rendered.
Clients are not reminded of their appointments. Healthcare providers cannot bill a client’s insurance for no-show or late cancelled appointments. Missed appointments (no-shows) are billed in full to the cash-paying or private insurance client. A credit card number is given at the time the appointment is made to ensure proper cancellation or postponement of scheduled services. Late cancellations or postponements (changed before appointment time but outside of cancellation grace periods below) are billed at ½ of the amount of the scheduled appointment time.
For Medicaid and Medicare clients, no credit card number is required pre-visit to ensure that the visit is cancelled or postponed appropriately; however, if a session is not cancelled or postponed appropriately, then service will not be rescheduled.
So that clients are not penalized for cancelled or changed appointments, the client agrees to cancel or postpone services with Beth Powell’s In-Family Services by phone call only between the hours of 8 a.m. and 6 p.m. Monday-Friday and understands that a changed or cancelled appointment is confirmed by a return call from the provider. See following cancellation policy below:
Tuesday-Saturday Appointments (no clients are seen on Sundays or Mondays):
1-2 hour appointment: 24 hour (1 business day) notice
Note: There is no exception to the cancellation policy, even in cases of emergency.
Your privacy is protected by federal and state law. You may not text or use unencrypted e-mail to communicate private health information with this office. The business phone for this practice does not receive texts or e-mails. What is said in this office will remain private and confidential under the guidelines of HIPAA, the Texas Social Work Code of Ethics, the Texas Social Work Licensing Board and Texas HB 300. All associates who are affiliated with Beth Powell’s In-Family Services and who have potential access to your personal health care information must sign a HIPAA-compliant Business Associate Agreement which ensures your confidentiality under law. By law, you are also required to receive and sign paperwork related to HIPAA for services to be rendered. You will be given a HIPAA Notice of Private Practices (NOPP) which explains exemptions to the confidentiality rule. Please note that any third party who is paying for your services has access to your health care records. It is a legal requirement to keep records, which include information such as name, diagnosis, date of service, type of service, billing information, evaluations and session narratives.
Please note that even though there are Saturday appointments, business hours for phone communication are only between 8 a.m. and 6 p.m. Monday through Friday. The answer machine is not checked after business hours. In case of after-hour emergencies, please call 911.
Children under the age of 18 do not make appointments for themselves. Their parent or parents make the appointments for them and accompany them into their therapy sessions.
Please do not come to your appointment more than 10 minutes early. Please do not drop by this office if you have no appointment as that is disturbing to other clients. $80 an hour is charged to the client for all business time outside the client’s therapy session. Testimony or advocacy in any type of court or potential legal proceeding is not within this health care provider’s scope of practice. A $30 fee will be charged for returned checks. Retrieval and delivery of client records is $25. Records will only be released to the client or to the custodians of the client.
If you have a question about the professional performance of Lucy (Beth) Powell, SW license 18222, please contact: Texas State Board of Social Worker Examiners P.O. Box 149347, Mail Code 1982 Austin, Texas 78714-9347 www.dshs.state.tx.us/socialwork 1-800-942-5540 (Complaint Hotline)
Note: There are no risks, only potential benefits to treatment at Beth Powell’s In-Family Services.
By submission of the below information, I (we) acknowledge I (we) have read, understood and agreed to the above information and have made a copy for my (our) records. Any information that was unclear has been explained.
Name of Client:
The initial appointment has been scheduled for:
From: 123456789101112 000510152025303540455055 AMPM
To approximately: 123456789101112 000510152025303540455055 AMPM
If we must cancel or postpone, we agree to do so at least one business day in advance as outlined above.
Today’s Date: July 18, 2019
Leave this empty:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Adult Consent to Treatment Form
Agree & Sign