Vincent J. Nerviano, Ph.D.
Licensed Psychologist

Client Informed Consent and Agreement to Pay for Scheduled or Rendered Services

(Please forgive the required cold and official legal language!!)
 
INFORMED CONSENT FOR TREATMENT AND OTHER RELATED PROFESSIONAL SERVICES

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.

CLIENT AGREEMENT TO PAY

Clients are responsible for payment in full at the time of the rendered service unless they are (pre) approved under a managed care, EAP or other related contract.  The co-pay or coinsurance is then due, if any, at the time of service.  You acknowledge the official cash rate for services as posted in this waiting room. (This applies if you are not covered by an insurance contract or the payer refuses payment.)  You also acknowledged that such fees do not include any special reports, verbal conferencing, document copying or court testimony which are subject to prepayment at a negotiated rate.  You represent that the requested or accepted services are not for any purpose of legal representation or litigation, whether civil or criminal, and must notify Dr. Nerviano if that changes.

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.

I  have read and fully understand the above conditions and information, and my signature signifies my agreement and acceptance of  the terms as stated, including my rights regarding privacy.

Signature: X______________________________________________________ Date: X________________________

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

    Click Here for Printable Consent / Agreement Form (.pdf file)
          (click here if you need to download the free Adobe Acrobat Reader)

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