Informed Consent and Permission to Perform a Psychological Evaluation
This form provides information about our services and about your and/or your child’s rights and responsibilities as a client. Your signature at the bottom indicates that you understand the information and freely consent to participate in or allow your child to participate in this assessment. This assessment will involve a direct assessment of your child’s needs as well as your completion of rating scales and an interview regarding your child’s developmental history. The typical evaluation typically last from 2-3 hours. At the end of the assessment I will provide you with diagnostic first impressions but an official diagnosis will not be given until all testing, rating scales, and parent interviews have been completed. Please be aware that it is occasionally necessary to gather additional information which is not readily available at the time of the appointment. In some cases you may be asked to complete additional ratings or provide the examiner with additional documentation regarding health and development. Reports are typically completed within 4-5 weeks and provided to both parents and participating agency. In the event you need documentation including a diagnosis in order to begin receiving therapy or treatment for your child, please indicate this at the time of the assessment or in a follow up email describing the need for such documentation as well as the related services.
Billing and Payments
Mountain West Autism Services has contracts with several insurance carriers. An option to selfpay is also available for services as well. If you are planning on self-pay please inquire about the approximate rates for an evaluation. Further testing may include additional fees at a specified rate. If you are using the self-pay option for the cost of the evaluation or are responsible for a portion of the assessment you have the option of paying online via credit card or with a check. If you will be paying online you will be provided with a secure link to make the payment after your child’s report has been sent to you. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. [If such legal action is necessary, its costs will be included in the claim.] In most collection situations, the only information I will release regarding a patient’s treatment is his/her name, the dates, times, and nature of services provided, and the amount due. In circumstances of 2 unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan if this information is disclosed in a timely manner. Although all claims will be filed with your insurance company, it is your responsibility to guarantee payment and to follow up with your insurance company if there are any questions. Any preauthorization which is required by your insurance company must be done prior to your scheduled appointment. If your insurance does not cover the current evaluation you will receive a bill and it is expected that payment will be made on a timely basis (within one month of billing). Any reimbursement issues are the responsibility of the client/member and the insurance company, not Mountain West Autism Services. Although optional, we request you leave a credit card on file. If your insurance company does not pay your claim within 30 days, you will be notified via email or phone and your card will be charged for the unpaid balance.
**Policy regarding comprehensive psychological reports**
In the event that you require the release of the psychological report quickly (i.e., prior to the receipt of payment by the insurance company) a $250 deposit may be required. This deposit is then refunded in full at the time payment is received by our office from the insurance company. In most situations we can provide a diagnosis verification letter and/or brief suggestion for services (i.e., “prescription” for ABA services). This service is provided at no charge.
Release of Information
Communications may occur by phone or in writing with your insurer for the purpose of conducting utilization reviews. Utilization reviews may require the release of written or verbal confidential information including psychological reports. You are directing Mountain West Autism Services to exchange information regarding your case, including release of a psychological report to agencies, doctors, therapists, or to anyone you authorize in writing. By authorizing release of information, I understand certain information may be released for the purpose of Mountain West Autism Services to obtain consultation regarding the current evaluation and/or treatment. I authorize the release of pertinent information requested by my insurance carrier for the purpose of processing my insurance claim and obtaining payment for services. In authorizing the release of information to any insurance company or other third parties, I understand that the information may become part of the third parties’ records and Mountain West Autism Services is not responsible for any subsequent release of information.
Please note that by signing this document you are aware that your insurance will be billed for this assessment. The majority of insurances do cover the full cost of an evaluation, however, in some cases you may be responsible for a portion of the cost of the assessment. This especially pertains to families covered by commercial insurance who have not met their behavior/mental health deductible for the year. In some cases families are able to utilize flexible spending plans or access a health savings account for reimbursement. If you are billed by Mountain West Autism Services and would like to submit for reimbursement through one of the aforementioned plans I will provide you with a super bill which may help you in receiving reimbursement. It is important that you find out exactly what mental health services your insurance policy covers prior to the assessment so you are aware of any fees you may incur. If you have questions about the coverage, call your plan administrator. I am also available to provide you with whatever information I can based on my 3 experience and will be happy to help you in understanding the information you receive from your insurance company. If necessary, we may be able to contact the insurance company on your behalf to obtain clarification. Your signature below indicates that you have read the information in this document and consent to having your child evaluated and you are aware that your insurance will be billed for the current assessment. Your signature also indicates you are aware that you may be responsible for the fees associated with the evaluation in the event that your insurance deductible has not been met or you do not have insurance coverage.
Check to Agree
I have read the above form
Acknowledge that the above form has been read and understood. Your digital signature below will be accepted as consent.
*Please provide your insurance information below
Name of Primary Household Member Insured