Consent to Treatment Form

Aetna and cash-paying clients may pay for services with cash, check or credit card (VISA, Mastercard, Discover).  $80 per 60-minute hour is the normal fee for services.   Aetna clients have co-pays and there are no out-of-pocket fees for services for TMHP Medicaid, Superior/Cenpatico Medicaid or Traditional Medicare clients.  If you have Aetna, please call them to find out what your in-network, outpatient psychotherapy benefits are.  Co-pays and 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 Aetna client.   A credit card deposit for ½ of the estimated cost of services is due 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.  The office is unable to make exceptions for no-shows, late cancellations or late postponements.  Debit cards are not accepted.  Length and cost of the session will be discussed and agreed on at the time the initial appointment is made.

For TMHP Medicaid, Superior/Cenpatico Medicaid and Medicare clients, no credit card deposit 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 services will not be rescheduled.

Cancellation Policy

So that clients are not penalized for cancelled or changed appointments, the client agrees to cancel or postpone services with 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 and Mondays):

  • 1-2 hour appointment: 24 hour (1 business day) notice

Note: Saturdays and Sundays are not business days and are not included in the above grace-period calculation.  Please note that no insurance company will pay for phone consultation.

Confidentiality

Your privacy is protected by law and Texas has one of the most stringent confidentiality practices.  Confidentiality laws in Texas will not permit any Skyping, texting, nor unencrypted e-mail of any sort between client and health care provider.     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 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.

General Information

Please note that even though there are Saturday appointments, business hours for communication are only between 8 a.m. and 6 p.m. Monday through Friday.  This practice is not open 24 hours a day.  In case of after-hour emergencies, please call 911.  Parents make appointments for children under the age of 18 and accompany them into the therapy session.

Please do not come to your appointment more than 10 minutes early.  The hourly therapy rate of $80 an hour is charged to write letters, and to research and send electronic records.  Lucy (Beth) Powell, LCSW, does not go to court nor talk to attorneys under any circumstances.  A $30 fee will be charged for returned checks.  Note:  There are no risks, only potential benefits to treatment at In-Family Services.  

Please separate entries below by commas in appropriate fields. 

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.