Intake Release Form

I understand that this evaluation may consist of formal testing of intellectual functioning. It may also include tests of academic achievement, memory, language, speech, social/emotional functioning, and/or visual-motor coordination. Psychometricians are typically used during the testing process. Doctoral trainees, under the psychologist’s supervision, may be involved in the evaluation process. I understand that psychological/educational/medical information can only be released with my signed consent except under the following conditions (and are explained further in the HIPAA Notice Form that will be available upon request):

  • Such information may be sent to the referral source
  • Such information may be sent to assist in processing the insurance claim(s);
  • Such information may be sent in response to a court order;
  • Such information may be sent when the patient has threatened harm to him/herself or to others;
  • Such information may be sent in response to suspected child or elder abuse;
  • Such information may be sent in defense of psychological practice.

I authorize and request payment of benefits from my insurance company directly to Southern Arizona Neuropsychology Associates, L.L.C. I agree that this authorization shall cover all services rendered until such authorization is revoked by me. I agree that a photocopy of this form may be used in place of the original.
I understand that I am responsible for paying any and all charges not paid by my insurance carrier.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO IT’S TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE THE RIGHT TO REQUEST THE HIPAA NOTICE FORM DESCRIBED ABOVE.
DISCLAIMER: Our office has provided you with a price estimate of your patient responsibility. Please note, this is an estimate only. It is difficult to give an exact quote, because billing is based on how many hours of testing and report writing are done by the psychologist. The approximate cost of this evaluation is $2000. Patients are responsible for any deductible, co-insurance, and co-pay assigned by the insurance company. Follow-up appointments may incur an additional cost. Self-pay patients are on a flat fee basis, and may disregard this disclaimer. Any payment arrangements must be made prior to the appointment date.
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