A PSYCHOLOGICAL CORPORATION
PSY 8534

 
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Informed Consent

 

PSYCHOLOGICAL COUNSELING
AND CONSULTING SERVICES

Steven T. Griggs, Ph.D.
Licensed Psychologist

    Encinitas Rancho                             PSY 8534
    Professional Park                                                     
    4407 Manchester Ave., #204                                             210 S. Juniper St., #205
    Encinitas, CA 92024               Fax: (760) 471-1844              Escondido, CA 92025
    (760) 746-8355                       http://drgriggs.org                         (760) 746-8355

                                                                    
By signing below, I authorize treatment and accept responsibility for all charges incurred in this office.   Counseling sessions, whether face-to-face or by telephone/video are normally forty-five minutes in length and will be billed at $150.00/session, adjusted down to my contract rate for your specific carrier, plus any co-pays and/or deductibles. Non-counseling session telephone calls over five minutes, record copying and all other case-related tasks (for example, non-court-related letters, additional billing for court battles) will be charged at the rate of $2 per minute.   This includes helping to figure out insurance benefits (beyond setting up telehealth sessions initially) or fixing billing problems.   Anything having to do with attorneys or courts, including writing letters, making telephone calls, giving depositions or testifying, will be billed at a different rate--the going rate for court services, which are considerably higher.  

I understand Dr. Griggs will bill my insurance/managed care company as a courtesy and that in order to do so I will provide the necessary information.  By signing below, I authorize my signature to remain “on file” for billing purposes only.  I also agree to keep any co-payment or deductible owed current on a thirty-day revolving basis, or pay a small monthly fee (a minimum of $5.00 or 1.5% of the unpaid balance, whichever is greater) for each thirty-day cycle re-billed.   Said monthly fee shall not apply to monies forthcoming from insurance companies, only to outstanding co-payments or deductibles.   In the event of accidental financial problem (e.g., bounced checks) there will be additional charges.)   Finally, should my account become delinquent (outstanding over sixty days), I agree to pay for all additional charges, fees or penalties incurred in attempting to collect.   Presently, collection agencies charge Dr. Griggs about 60% of any submitted amounts.   Consequently, if my account goes to collections, I authorize Dr. Griggs to add this amount to the balance due prior to submitting it to cover their costs, without penalizing Dr. Griggs.

I agree to give Dr. Griggs twenty-four hours notice when I need to change or cancel appointments.   I further agree to notify him during normal business hours by telephone, NOT by fax, NOR by email, NOR by text; none of which are timely, NOR CONFIDENTIAL.  (Emails and texts received that look like they may contain confidential information--scheduling or billing--will be deleted, unopened, for liability reasons.)   “Normal business hours” are Monday through Friday, 9:00 a.m. to 5:00 p.m., exclusive of holidays. If I do not give twenty-four hours notice or if I notify him outside of the above hours (for example, calling on a Saturday, Sunday or a legal holiday, or calling after 5:00 p.m. to cancel an appointment for the following business day, or by sending an email or text), I will remain financially liable for the full billable amount of that appointment.  

I understand any information I communicate to Dr. Griggs will be held in confidence and will become part of my records, accessible only to Dr. Griggs.   The exceptions to this are if I give my insurance/managed care/telehealth company access to my records, or if I wish Dr. Griggs to bill my insurance/managed care/telehealth company on my behalf.   I understand records also can be surrendered under court ordered subpoena or via audit from my insurance company.   In other routine matters or third party communications having to do with my case information, I will sign a Release of Information form if records are to be released.   If I send confidential information to Dr. Griggs, it will be via HIPAA compliant channels.

Finally, I understand that this agreement does not specifically guarantee that we will attain our therapeutic goals; however, it does constitute an offer on my part to contract with and to reimburse Dr. Griggs for access to his resources as a psychologist, and his willingness to apply his therapeutic resources in good faith.

 

_____________________________________________________________________
Client Signature            Date                                Dr. Steven T. Griggs              Date

 

 

Copy, print and fax this signed form to:

 

760.471.1844