Trenton J. Williams, Ph. D

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Trenton Williams, Ph.D. APPOINTMENTS: Your appointment begins at our agreed upon time, not when you arrive. It is important to be on time because your appointment cannot be extended beyond the scheduled time since other people may have reserved that time. Your appointment time is held exclusively for you. If you are unable to keep your appointment for any reason, you must give at least 24 hours advance notice to cancel; otherwise you will be charged $75.00 for the time reserved for you. This office does not give reminder calls for appointments. It is your responsibility to remember and keep track of your appointments. Your insurance company is not responsible for missed appointments and cannot be billed. GUARANTEES AND PROMISES: When you request treatment or an evaluation for yourself or for a person for whom you are responsible, be assured that I shall do my best to perform all services in a professionally competent manner. My training at California School of Professional Psychology (Ph.D. in Psychology) and Post-Doctoral Internship stressed an eclectic therapeutic orientation to different problems. I will endeavor to explain to you the kinds of treatments that are typically used, approaches to assessment and length and course of treatment for the issues or problems discussed. In this regard, it is always appropriate and I encourage you to raise questions about the nature and course of treatment. There are no guarantees that the results of any evaluation or therapy will conform to your every expectation. I make no promises to determine any particular diagnosis or to reach any particular conclusion for an evaluation. In fact, effective psychotherapy is sometimes confusing, and it is sometimes emotionally painful. Effective treatment and accurate assessment depend to a significant degree on your openness, your commitment to change, and collaboration; much of the responsibility for a successful outcome is yours. ETHICS AND PROFESSIONAL STANDARDS: As a member of the Washington State Psychological Association and as a Psychologist licensed by the Board of Psychological Examiners, I work to uphold the highest ethical and other professional standards at all times. The Board of Psychology Examiners in Olympia (753-9772) is also available to respond to your questions or concerns. EMERGENCY CALLS: An Answering Service takes all emergency calls outside of regular business hours. This service will attempt to locate me in the event of an emergency. Fees for reports, letters, review of materials, and phone calls may be charged on a pro-rate basis according to time actually required. PLEASE UNDERSTAND I DO NOT PERFORM EVALUATIONS OR ASSESSMENTS FOR LEGAL PURPOSES, SOCIAL SECURITY DISABILITY, OR PSYCHOLOGICAL REPORTS. BILLING AND PAYMENTS: Patients or their responsible legal guardian are responsible for their accounts and are expected to pay their bill when due, whether medical insurance pays for a portion or not, including charges for evaluation, printed materials, reports, letters, consultations and telephone calls. In families in which divorced parents are each legally responsible for a portion of the child’s bill, the custodial parent will be considered solely responsible for the entire bill. We cannot sort out which portion belongs to which parent, nor will we directly bill the non-custodial parent. Duplicate copies of the bill will be provided upon request, but all other arrangements are the responsibility of the custodial parent. A finance charge of 1% per month will be added to any balance not paid within 60 days after the charge was incurred. When 90 days have passed without a payment or prior arrangement with me, accounts may be sent for collection and the patient or legal guardian may be responsible for any additional legal and/or collection agency charges. Results of evaluations or reports may not be released until accounts are paid in full. It is recommended that you pay the portion of your bill which your insurance will not cover after each visit. Balances which patients allow to accumulate can begin to look very intimidating and may, in fact, interfere with the therapeutic process. We understand that this is an expensive treatment and we are prepared to arrange an extended payment plan. This entails a written agreement to pay a fixed amount regularly each month until the balance is paid. If regular payments stop, the balance will be considered delinquent, and the finance charges and collection procedures detailed above may be instituted. Bills are sent out monthly and detail dates of visits, the type of service provided, whether your insurance company had been billed for that visit, and all payments made into your account. If you have any questions about your bill, please ask me or my bookkeeper. She can be reached at 475-6021. INSURANCE: I am a contracted provider for many, but not all, local insurance companies. You should be sure to check with your insurer and my intake office to learn whether I am a provider for your plan. You should also learn whether you need a referral or preauthorization in order to be eligible for your mental health benefit, whether you have a separate annual deductible for mental health, and whether your mental health benefit has a maximum yearly number of visits or a maximum yearly dollar amount. My billing department will submit claims to insurance companies that I am contracted with. In order for this to occur you must complete the insurance portion of the “Patient Information” form that was given to you with this office policy; you also need to provide a copy of your insurance card. CHANGES TO THIS OFFICE POLICY: From time to time I may change the business policies described in this document; I will attempt to inform you of relevant changes. INFORMED CONSENT: I hereby authorize Trenton J. Williams, Ph.D. to render psychological services. This authorization constitutes informed consent without exception. I have read and understand the office policy statement and have received a copy of this office policy for myself. ** My electronic signature acknowledges that I have read and agree to the terms in the before mentioned office policy. ***

* I acknowledge I have read the financial policy above and that I am responsible for all charges regardless of any insurance coverage I have. I understand that delinquent accounts may be assigned to a credit reporting collection agency and agree to pay for all legal costs and expenses including reasonable attorney fees. By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

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