Pursuant to professional ethics and applicable state and federal law and regulation, all clients and/or legal guardians have a right to refuse client participation in any treatment service.  In any event there can be no guarantee of any particular outcome of services except for the provision of services within Dr. Nerviano’s current scope of practice as a Licensed Psychologist. There may also be additional limits imposed by your insurance provider or managed behavioral health care organization, or by you.

Dr. Nerviano also has a corresponding right to refuse or withdraw professional services for appropriate professional cause.  This includes your refusal of, or lack of cooperation with, services deemed necessary for minimal successful care. The client is responsible for any consequences of any such refusal, especially if under externally imposed mandatory services, i.e., EAP conditions of employment, and / or orders of any court of jurisdiction, probation department, etc.

You have the right to contact your insurance company or HMO directly for clarification on your rights or eligibly. Your consent, or withdrawal of same, does not effect any applicable law, regulation or ethical standard regarding mandatory reporting of events to authorities or emergency actions under civil or criminal law.  However you retain all you specific rights to privacy under Federal and Pennsylvania law or regulation, which can be explained to you at your request: none of these rights is waived.

You always have the right to have your services and treatment plan explained to you in a manner you can understand. Written policies, procedures and protocols for Life Safety, No-Shows, Sentinel Events, Privacy, and Complaints are also posted and available. If you are signing as parent or guardian for a dependent minor, by your signature you are attesting to your right to do so and agreeing to keep Dr. Nerviano informed, ongoing, of any changes which might effect your ability to fully consent and to verify such authority if necessary.

You also acknowledge and agree to the following:  No insurer pays for missed appointments, or late cancellations (e.g. less than 48 hrs. notice). Absent an emergency, or other mutually agreed changes, such problems are subject to a $50 fee, if paid within the week. Without payment, routine rescheduling may not be possible, and subjects the client/guardian to be personally responsible for the full posted fee. Accounts that are given to a collection agency, or that are settled by legal action, will then also include all collection, attorney, court or related service fees in addition to the full balance then due. Checks that are not cleared due to insufficient funds, or other reasons, are subject to a $30 service fee per returned check.

Client name if different than self (i.e., dependent):_____________________________________________________