Neuropsychology Services of Kansas

10111 E. 21st Street N.,
Suite 401

Wichita, Kansas 67206


Monday - Friday

8AM - 5PM


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I understand that it is my right to elect to whom my medical, insurance, and/or financial information can be released. For our records the first person listed will be your emergency contact. I also understand that if I choose to leave this information to anyone, including my spouse/significant other, children, parents, siblings, etc. I therefore authorize Neuropsychology Services of Kansas to release my information as directed below.



I do hereby authorize the release of any medical information necessary to process claims on my behalf. I request that all benefits be paid directly to Neuropsychology Services of Kansas for all charges incurred by me. I understand that I am responsible for all charges incurred during my treatment at NSK regardless of insurance coverage. I agree to pay the entire balance of my account in a timely manner.

Clinic Policies

Please Read The Following Carefully

CONFIDENTIALITY: All communication between you and the clinic is held in strictest confidence and will not be released unless: ( 1) you authorize release of information with your signature; (2) you present with potential harm to yourself or others; (3) there is suspicion of abuse or neglect of a minor or elder; or ( 4) the clinic is required to do so by Federal, state or local law.

EMERGENCIES: In case of emergency, call 911 or go to your nearest emergency room. For non emergency calls you may call the office at 316-867-3434, leave a message if necessary. Your phone call will be returned within one business day.

INSURANCE, CO-PAYS, DEDUCTIBLES AND BALANCES: Come to your appointment prepared to make a payment for co-pays, deductibles, balances and charges not covered by your insurance company. We file insurance claims for you as a courtesy. However, unpaid claims due to changes in coverage are your responsibility. Please call us if vour coverage changes between appointments.

APPOINTMENTS: Please call the clinic at least 24 business hours before your appointment if you need to cancel or reschedule. If an appointment is not canceled at least 24 business hours in advance you will be billed a seventy-five-dollar ($75) fee for interview, three-hundred- and fifty-dollar ($350) fee for testing, and seventy-five-dollar ($75) fee for feedback; this will not be covered by your insurance company. Three (3) missed appointments within 12 months will require signing of cancellation policy before setting up next appointment or may result in dismissal from practice.

RESEARCH: NSK works with physicians who are performing a variety of research projects. We may discuss these projects as viable alternatives or additions to your regular care. You may be asked to participate in this research, but you are under no obligation to do so.

SECURITY CAMERAS: NSK reserves the right to monitor security cameras in work areas for specific business reasons, such as security, theft protection or protection of proprietary information. This is for your safety and our safety.

NOTICE OF PRIVACY INFORMATION: If you wish to see our privacy policy or would like a copy, please ask our front desk.

I have read, fully understand and accept responsibility for each item described above.

This document is to obtain your informed consent for evaluation and treatment. Please ask your provider for clarification if you do not fully understand the recommendations. I hereby consent to a neuropsychological evaluation and subsequent treatment, subject to my ongoing involvement in providing consent. I understand that if I wish to accept treatment, I have the right to have the risks and benefits of treatment options explained to me to my satisfaction, including not having any treatment. I understand that I may at any time refuse any intervention in which I do not wish to participate.

Neuropsychology Services of Kansas

10111 E. 21st Street N., Suite 401

Wichita, Kansas 67206


Monday - Friday

8AM - 5PM

Phone: 316-867-3434

Fax: 316-867-3435