Richard O. Temple Ph.D.

Personal Data

Last Name:

First Name:

Date of Birth:

Age

SSN:

Ethnicity:

Occupation:

Employer:

Home Street Address:

City:

Zip Code:

Best Contact Phone Number

May We Leave a Message?

Yes No

Secondary Phone Number

Email address

Have you been in therapy in the past

Yes No

If yes, when?

Length of treatment?

Outcome?

Current Medications:

Have you ever been hospitalized for psychological reasons?

Yes No

If yes, when?

Length of Stay?

How did you hear about Dr. Temple's Practice?

INSURANCE INFORMATION

Primary Insurance:

Member ID #:

Group #:

Insurance Street Address:

City:

State:

Zip:

Insurance Provider Phone Number

Policy Holder Name:

Relation to Patient:

Policy Holder DOB:

Policy Holder SS#:

Policy Holder Phone #:

Policy Holder Address:

City:

State:

Zip:

Policy Holder Employer:

Secondary Insurance:

* I hereby authorize Richard O. Temple, Ph.D. to provide information to my insurance carriers concerning my diagnosis and treatment. I hereby authorize Richard O. Temple, Ph.D. to provide treatment to me/and or my dependents. I authorize payment of medical benefits to Richard O. Temple, Ph.D.

Signature

Date

Emergencies:

If there is an emergency during our treatment process, either during or outside a therapy session, I will do whatever I can, within the limits of the law, to prevent you from injuring yourself of others and to ensure that you receive the proper medical care. This may include contacting the person you designate below as your emergency contact. Additionally, your consent is not required if you need emergency treatment, as long as your consent is sought after treatment is rendered, of if I attempt to get your consent and you are unable to communicate. If you experience an emergency outside of our therapy sessions, you may call 911 or go to your nearest Emergency Room for a risk assessment to determine your need for hospitalization to ensure your safety.

Emergency Contact:

Phone Number:

Relationship to Patient:

If you have any questions about the above information, or if you have questions about a specific situation, please feel free to discuss your questions or concerns at any point during the therapy process. I have carefully read, understand, and agree to comply with the above office policies and consent for treatment for psychotherapy/testing services.

Date

Parent/ Guardian or authorized Surrogate Signature

Date

I authorize the release of my psychological treatment information to the person(s) listed below:

Name of Person(s) or organization(s):

Street address, City, state, and Zip code:

Telephone Number:

Fax Number:

Guarantee of Payment for Service:

We are committed to providing you with the best possible care. If you have medical insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and understanding of our payment policy. Payments for services are due at the time services are rendered unless payment arrangements have been approved in advance by our staff. We accept cash, checks, Visa, Mastercard, and Discover.

We will be happy to file all primary insurance for you as a courtesy. However, you must realize:

Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract.
Not all services are covered by insurance contracts.
If your insurance chooses to not pay for our services, your portion will not exceed $2000.
We may need to release medical information concerning you to your insurance carrier as part of processing your claim. By signing this form, you consent to the release of such information, including medical records, to be released to insurance companies, referring physicians and other doctors involved in your care.
All charges are your responsibility from the date the services are rendered.
All co-pays are due at the time of service.
A No-Show is is defined as a patient who does not appear for the scheduled appointment. or cancels at the last minute - giving our office insufficient amount of time to fill the appointment slot.
There is a $30 charge for returned checks. (fee subject to change)
There is a $150 fee for no-shows and cancellations with less than 24 hours of notice
There is a $500 fee for for no-shows and cancellations of Neuropsychological testing appointments with less than 24 hours of notice
Patient balances over 60 days old will be assessed a 2% per month charge on outstanding balances.
Accounts over 90 days old will be turned over to a Collection Agency. Your future status at this office will be considered at that time. We reserve the right to release to a collection agency the information necessary to collect outstanding fees.

By signing this form you agree that you will be responsible for reasonable costs, including attorney’s fees and interest we incur if your account becomes past due and is turned over for collections.

I understand and accept the above terms and provisions.

Signature

Date

No Show, Late Cancellation and Co-payment Policy

1. I understand that I will be charged a LATE CANCELLATION fee of $500 if I fail to give 48- business hours notice (For Monday appointments that means 8 am on the Thursday before the appointment) prior to cancelling my testing appointment.

Initial:

2. I understand that I will be charged a NO-SHOW fee of $150 for therapy appointment if I fail to show for my appointment or cancel less than 24 business hours (For Monday appointments that means 8 am on the Thursday before the appointment) prior to canceling my appointment

Initial:

3. I understand that I am responsible for knowing my co-payment amount and deductible amounts.

Initial:

Have you met your deductible for this year?

Yes

If no, how much more do you have to pay towards your deductible?

4. I understand that I will be charged a $10 service charge if I fail to make my payment and/or co-payment at the time of my appointment.

Initial:

5. I understand that these charges are an out of pocket expense and that my insurance carrier will not cover these charges.

Initial:

6. I understand that the therapy session will last 60 minutes. I understand that if I am late to the appointment, I will still have to end the session at the allotted time. By signing this, I am agreeing to the above stated terms and stipulations regarding the services I receive from this therapist.

Signature

Informed Consent Neuropsychological Examinations

You have been referred for an independent neuropsychological examination. (i.e., evaluation of your thinking abilities and emotional status) by

Nature and Purpose:

The goal of neuropsychological assessment is to determine if any changes have occurred in your attention, memory, language, problem solving or other thinking skills, as well as your emotional functioning.

A neuropsychological examination will include an interview, where questions will be asked about your background and current medical symptoms. Additionally, standardized tests and other techniques may be used, including, but not limited to, asking questions about your knowledge of certain topics, reading, drawing figures and shapes, learning word lists or stories, viewing printed material and manipulating objects. Your task is to answer questions as accurately as you can; for example, when discussing your problems, do not minimize significant problems, but also do not exaggerate lesser concerns. You are to give your best effort during the testing. This does not mean that you must get every answer or problem correct, for no one ever does. However, you do have to give your best effort. Part of the examination will address the accuracy of your responses, as well as the degree of effort that you exert on the tests.

Foreseeable Risks, Discomfort, and Benefits:

For some individuals, neuropsychological examinations can cause fatigue, frustration, and anxiousness. An attempt will be made to help you minimize these factors. The results of this examination may either support or not support your claim.

Results of the evaluation:

The results of this evaluation will be communicated directly to your health care providers in the form of a written report. You will also have the opportunity to receive feedback on the results after the evaluation and report have been completed.

Signature

Limits of Confidentiality:

The results of this examination will be forwarded to

Dr. Temple is not responsible for the information being re-released by parties to whom you agreed the he release the information to. Beyond the above, confidential information about you obtained during the examination can ordinarily be released only with your written permission. There are some special circumstances that can limit confidentiality, which include, but are not limited to, (a) a statement of intent to harm yourself, or others, (b) statements indicating harm or abuse of children or vulnerable adults, and (c) a subpoena from a court of law.

I have read and agree with the nature and purpose of this examination and to each of the points listed above. I have had an opportunity to clarify any questions and discuss any points of concern before signing.

Signature

Date

Signature of Guardian

Date

Time Limit of Doctor-Patient Relationship

By participating in this evaluation, we are establishing a doctor-patient relationship. Following todays’ treatment, you will be considered a patient of Dr. Temple’s for the next 365 days. If no additional contact is made with Dr. Temple in that time frame, you will be considered discharged from his care. After that time, you are of course welcome to contact Dr. Temple about future treatment, but for the purpose of the professional relationship, you will be considered a new patient and thereby the provision of such services is not guaranteed.

Signature

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Signature of Guardian

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