Thank you for selecting the neuropsychology practice of Bonnie Connor, PhD. The following information describes the policies and procedures of my practice regarding the scheduling of appointments, the payment of fees, and the use of medical insurance.

Appointments and Cancellations: Each appointment involves the reservation of time specifically for you. A minimum of 24 hours (1 day) notice is required for re-scheduling or canceling an appointment. The full fee will be charged for appointments missed without such notification, and are due and payable by the next visit. Insurance companies do not reimburse for missed sessions.

Services: The neuropsychological evaluation is a comprehensive process that includes:
• Completion of the Biographical Questionnaire and self-report measures about your brainrelated symptoms and emotional functioning. (Approximately 1 hour)
• An extensive interview (face-to-face or teleconference) during which we discuss your background and current symptoms. The interview includes relevant developmental and psychosocial, school and academic, employment, family, and medical history; and results of any previous psychological, psycho-educational, or neuropsychological testing. (Approximately 1 to 2 hours)
• Face-to-face assessment (testing) with standardized tests sensitive to areas of brain function important in everyday life such as attention, concentration, processing speed, mental flexibility, language, visual spatial abilities, memory, and thinking. As appropriate, academic achievement tests (e.g. language, reading, spelling, and math) are given. (Approximately 4 to 6 hours, or more, depending on the referral question and other factors.)
• Feedback about your performance on testing including: discussion of your brain-related and emotional strengths and weaknesses; recommendations to guide treatment for your personal, educational or vocational needs; and make relevant recommendations to your other health care provider(s). (Approximately 1 to 1.5 hours)
• A written report. The outcome of neuropsychological evaluation is a written report in which conclusions are made about your overall functioning. The report may include specific recommendations to guide treatment or enhance your overall functioning in everyday life. The conclusions and recommendations are developed by integrating information obtained from the standardized testing, interviews, records and other observations.
 
The neuropsychological evaluation process, including additional time required for scoring, interpreting, and analyzing test results, report writing, and feedback is described in detail in the Consent for Neuropsychological Services. Services may be billed on days when there is no face-to-face contact.
 
Payment for services rendered: I am obligated to bill your insurance company only if I am a contracted provider. I am a contracted provider for UC SHIP and TriCare. With these insurance plans you agree to assignment of benefits to Bonnie Connor, PhD.

You will be responsible for any deductible, co-payment, or specialty service fee (UC SHIP $200 deductible) not covered by your insurance. (UC SHIP 20% co-payment for neuropsychological testing is waived).

It is your responsibility to file claims with your insurance company for any and all services provided by Bonnie Connor, PhD, unless I am a contracted provider (see above). If requested, I will provide you with a “superbill” to submit to your insurance company. Because you have paid 1 for the evaluation, any reimbursement from insurance will go directly to you. It is your responsibility to determine whether your insurance company will reimburse you.

Payment: For deductibles, co-pays, and self-pays you may pay by clicking on the ‘payment’ button on my web site: www.bonnieconnor.com. If you are paying by check, please make checks payable to: Bonnie Connor, PhD. There is a $25 fee for returned checks. My fee is $150 per hour for neuropsychological evaluation. Cases involving litigation are billed at a higher rate depending upon the complexities of the case.

Telephone or Teleconference Consultations: By prior arrangement.

Email: You may communicate with me using my HIPAA compliant secure email account: bonnie@secure.bonnieconnor.com. Appointment scheduling and brief questions can be addressed via email. I do not discuss diagnosis, treatment, or recommendations by email. Active duty military need to use a private email account—not “.mil” account.

Reports and Consultations: Neuropsychological evaluation reports are billed based on total time spent in face-to-face interviewing and testing, and non face-to-face scoring, interpreting, analyzing, and report writing. Please see Consent for Neuropsychological Services for details.

Telephone calls and professional consultations with physicians, health care providers, attorneys or others as needed related to your treatment must be paid in advance and will be charged at the rate of $150 per hour. Contact with other service providers requires your consent.

Confidentiality: All information disclosed within sessions, and the written records pertaining to those sessions, is confidential, within the limits of California law, and may not be revealed to anyone without your written permission, except when disclosure is required by law.* In the event that I must contact another individual or agency regarding you or your situation, I will make every effort to obtain your written or verbal consent. Certain disclosures may be requested by your insurance. I am not liable for how this information is utilized or the nature of the inquiries.

*Psychologists are mandated by law to report to the appropriate authorities, with or without client consent, suspected child abuse, elder abuse, dependent adult abuse, or the intent to harm self or others.

Social Networking: I do not accept friend requests from current or former patients on any social networking sites (Facebook, LinkedIn, etc). Adding patients as friends or contacts on these sites compromises your confidentiality and our respective privacy. I request that you do not communicate with me via any interactive or social networking web sites.

In case of an emergency, please call 911 or go to your closest emergency room.

I have carefully read this agreement and my questions were answered by Bonnie Connor, PhD.
 
 
 
 
 
 
 
 
   

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