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.
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
ask our front desk.
I have read, fully understand and accept responsibility for each item described above.
CONSENT FOR OUTPATIENT TREATMENT
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.