Download informed consent and assignment of benefit

INFORMED CONSENT AND ASSIGNMENT OF BENEFIT
I consent to psychological services to be provided by Deer Oaks. I understand my evaluations and treatment are confidential,
but there are limits to confidentiality. Confidential information may be disclosed under the following conditions:
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I have been evaluated to be a danger to myself or others
My treating clinician believes I am the victim of abuse or if I divulge information about such abuse
I give consent to disclose information
I authorize Deer Oaks to consult with and discuss the results of my confidential evaluation and treatment with the medical,
nursing, and therapeutic staff in order to facilitate the highest level of medical restoration and quality of life. I also authorize Deer
Oaks to furnish information to my insurance carrier concerning my diagnosis, treatment and related matters. I assign to Deer Oaks
all payments for professional services rendered, and I understand that I am responsible for paying Deer Oaks for the amount
not covered by my insurance.
I understand that Deer Oaks only provides professional therapeutic services to clients, and will not engage in any personal
relationship with clients and their families outside of the professional relationship.
I acknowledge that Deer Oaks accepts Medicare, Medicaid and supplemental insurance for services provided. As a courtesy to
patients, Deer Oaks will bill my insurance(s) for these services. In the event I have Medicare and Medicaid, or Medicaid only;
I understand that I am not obligated to pay additional co-pays and will not personally be billed for these services. I am
aware that Medicare may adjust their rates yearly and not all supplemental insurance(s) pay the entire co-pay. If I do not have
Medicaid, I understand that the co-pay will be billed to me or to my secondary or supplemental insurance. If Deer Oaks is not on
my insurance panels, I understand that the insurance may or may not pay the entire co-pay amount or the insurance may pay me
directly. I fully understand that any payments received by me for services provided by Deer Oaks are payable immediately to Deer
Oaks. I acknowledge that Deer Oaks will bill me for services provided, if not covered by Medicare and Medicaid. Deer Oaks
cares about the treatment of their patients, and is willing to establish a monthly payment plan, should I have a deductible or copayment after Medicare has paid. The approximate co-pays are as follows, but may vary depending on geographic
locations/Medicare pay localities:
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Diagnostic Interview co-pay amount is $25.82 or less
20-37 minutes of individual therapy co-pay amount is $12.53 or less
40-53 minutes of individual therapy co-pay amount is $16.66 or less
45-50 minutes of family therapy with patient co-pay amount is $20.92 or less
Psychological Evaluation /Assessment co-pay amount is $164.78 or less
These amounts are based on the Medicare fee schedule effective 01/01/16 and are subject to change without advance notice.
Please call 1-888-365-6271 for information or assistance.
Consent for release of confidential information. Please initial in the space provided.
(____) I consent to the release of all information regarding my care to my financially responsible party and/or family members
involved in my care.
(____) Exceptions to consent - I do not wish to release information to the following person (s)_________________________
(____) I acknowledge that I have received and understand the Deer Oaks HIPAA and Notice of Privacy as provided by Deer Oaks.
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Patient’s Name (Print)
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Patient's Signature & Date
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Patient’s Representative’s Signature & Date
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Relationship to Patient
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Deer Oaks Representative’s Signature & Date
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Name of Facility
2016 Informed Consent Kansas