DISCLOSURE AND POLICY STATEMENT

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Geoffrey Blankenship
6 years ago
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1 ERIN A. BEASLEY, Ph.D. Licensed Child & Adolescent Psychologist (206) DISCLOSURE AND POLICY STATEMENT PLEASE READ AND SIGN Welcome to my practice. I am pleased to have the opportunity to work with you. These office policies are provided for your information. Please ask me if you have any questions. As a psychologist licensed by the Washington State Examining Board of Psychology, I subscribe to the APA Revised Ethical Principles. I am an independent practitioner and am solely responsible for the services I provide. Though I am leasing space that houses other psychologists, I am not affiliated with any of them in connection with the clinical services that I am providing to you or any other clients. I am not responsible or liable for the practices of any other practitioner and they are not responsible or liable for my practices. Education, Training, and Licensure I received a Bachelor of Science in Psychology from the University of Georgia and a Master of Arts in Psychology from the University of Denver. I obtained my doctorate in Counseling Psychology from the University of Georgia, specializing in child assessment. My pre-doctoral internship was at the Central Alabama VA Hospital, where I completed rotations in neuropsychology, health, and rehabilitation psychology. Then I completed a post-doctoral fellowship at the Children s Healthcare of Atlanta (Marcus Autism Center) where I received specialized training in the early identification of Autism Spectrum Disorder, as well as assessment of early development and learning. I was in private practice in Atlanta, Georgia for two years providing psychological, learning, and developmental evaluations for children and adolescents. During this time, I also worked at the Georgia State Regents Center for Learning Disorders where I provided comprehensive learning evaluations for college and graduate students. I then served as Clinical Faculty in the Department of Medical Genetics at the Greenwood Genetic Center in Charleston, South Carolina where I monitored the developmental, neurological, and psychological functioning of children with inherited metabolic disorders. Upon moving to Seattle, I joined the University of Washington Autism Center where I provided diagnostic evaluations for children, with a focus on early identification of Autism Spectrum Disorder and differential diagnosis of children with speech and language disorders, developmental delays, attention and learning concerns, and social-emotional issues. I am licensed as a psychologist in the state of Washington (# ). Psychology licensure requires that psychologists have passed a national written exam and a state exam given by the Washington State Examining Board of Psychology. Inquiries about my qualifications and any complaints about my professional services may be directed to: State of Washington Department of Licensing Health Care Licensing, Psychology Section PO Box 9649 Olympia, WA (360) of 5

2 Confidentiality and Records My practice is compliant with the privacy rules of the Federal Health Insurance Portability and Accountability Act (HIPAA). Please see my separate Notice of Privacy Practices for detailed information regarding how I will handle health care information collected about you in my practice. For clients who are under 13 years of age who are not emancipated, the law may allow parents to examine their child's mental health records. I am completely independent in providing you with clinical services and I alone am responsible for those services. I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to our work together. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. Exceptions to Confidentiality There are some situations where I am permitted or legally required to disclose information without either your consent or authorization: If I have reasonable suspicion that a child has suffered abuse or neglect, the law requires that I file a report with the appropriate government agency. If I have reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, the law requires that I file a report with the appropriate government agency. If I have reason to believe you or someone else is in imminent danger, I may be required to take protective action, including notifying potential victims, contacting the police, seeking hospitalization for you, or contacting family members or others who can help provide for your protection. If a government agency is requesting the information for health oversight activities. If you file a complaint or lawsuit against me, I am permitted to disclose information as relevant for my defense. If you file a worker s compensation claim, and your evaluation is relevant to the injury involved in your claim, if properly requested, I must provide a copy of your record to your employer and the Department of Labor and Industries. I am required to report myself or another healthcare provider in the event of a final determination of unprofessional conduct, a determination of risk to client safety due to a mental or physical condition, or if I have actual knowledge of unprofessional conduct. If you have any questions or concerns about this requirement, please talk with me about them. 2 of 5

3 Communication Agreement I will use reasonable means to protect the security and confidentiality of sent and received. However, there are known and unknown risks that may affect the privacy of personal health care information when using to communicate. These risks include, but are not limited to: can be forwarded, printed, and stored in numerous paper and electronic forms and be received by unintended recipients without my knowledge or agreement. may be sent to the wrong address by any sender or receiver. is easier to forge than handwritten or signed papers. Copies of may exist even after the sender or the receiver has deleted his or her copy. service providers have a right to archive and inspect s sent through their systems. can be intercepted, altered, forwarded, spread viruses, or be used without detection or authorization. delivery is not guaranteed. Please note that the confidentiality of communication is not guaranteed to be secure. At this time, I do not use with clients. However, if you sign a release, I may use to communicate with other professionals and school personnel that you designate to obtain information about your child s functioning in other settings. By signing below, you give me permission to send messages that include client health care information and you acknowledge that you have read and understand the risks of using as stated above. If you are not comfortable with me using to communicate with other professionals, with a Release of Information, please make this request immediately and in writing. Contacting Me/Emergencies At any time, you may leave a confidential voic message for me at I check my messages regularly, and will make every effort to return your call within 48 hours (excluding weekends and holidays). Please provide me with times when you will be available. Please note, I am with clients most of the time I am in the office, but I will make an effort to return your call as soon as I am able. If your call is urgent, call the Crisis Line at ( ), go to the nearest emergency room, or dial 911. If I am gone for an extended period of time, I will arrange for a colleague to be available. Billing and Insurance You are expected to pay for the full cost of the evaluation at the first testing appointment. I do not currently maintain private contracts ( Preferred Provider status) with ANY insurance companies and am, therefore considered an out-of-network provider for all insurance companies. I recommend that you contact your insurance company prior to testing. I can provide the CPT codes, my NPI number, and an estimate of billed hours. It is your responsibility to send the invoice I provide to the Claims Department of your insurance company so that you can receive the appropriate reimbursement. If your insurance company requires 3 of 5

4 additional documentation regarding our work together beyond standard billing statements, there will be a charge for time spent preparing these reports. Payment by check is preferred. Checks should be addressed to Erin A. Beasley, PhD, PLLC. A credit card or HSA card may be used, but the Stripe credit card processing fee (3%) will be added to your bill. I am currently not contracted with any insurance companies and, thus, I am considered an out-of-network provider for all insurance plans. I bill by the hour and I will provide you with an invoice when I send your written report. If you need an invoice prior to the final report, please let me know and I will provide one at the feedback appointment reflecting the services provided. Please note that payments returned as NSF (nonsufficient funds) by the bank or credit card will be charged an additional 5% service fee. Professional Fees A complete psychological evaluation (children to young adults ages 1-18) is billed at $225 per hour effective January 1, 2018, which includes all work performed in support of the evaluation, interview, consultation with other providers, review of pertinent documentation, 5-8 hours of testing, scoring/interpretation of all tests, a 90-minute feedback session, and completion of a written report. A complete psychological evaluation typically takes approximately hours to complete. Appointments and Cancellations Your appointment time(s) is set-aside exclusively for you and your child, and I cannot fill that time slot without sufficient notice. To cancel an appointment, please provide at least 48 hours notice, or you will be billed at a rate of $225 per hour for testing appointments; the time that has been set aside for your child s session, unless we both agree that the appointment was unable to be kept due to circumstances beyond your control (e.g. illness). If you will be arriving late to an appointment, please call my office as soon as possible so that I know you are coming and have not forgotten about the appointment. If you arrive late for an appointment, you will be billed the full fee for your session. Please note that insurance companies will not provide reimbursement for cancelled sessions. Other Professional Services I charge $225 per hour for other professional services, including school consultations, attendance at meetings with other professionals you have authorized, program evaluations, and the time spent performing any other service you may request. If you request a classroom observation the cost for drive time is equal to my hourly fee ($225). If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $ per hour for preparation time, drive time, and attendance at any legal proceedings. A retainer of $ is required prior to any participation in legal proceedings. 4 of 5

5 Delinquent Accounts If your account has not been paid for more than 90 days and arrangements for payment have not been agreed upon, I retain 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 release regarding a client s treatment is his/her name, the nature of services provided, and the amount due. These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action. Informed Consent Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. I have read the above and have had the opportunity to ask questions. I give permission for evaluation and treatment for myself (13 years or older). I have read the above and have had the opportunity to ask questions. I give permission for evaluation and treatment for my minor child (12 years of age or younger) and state that I am the parent or legal guardian for the child. Relationship to client: Relationship to client: 5 of 5

Education, Training and Licensure

Education, Training and Licensure Meredith M. Sargent, Ph.D. Licensed Clinical Psychologist 2950 Northup Way, Suite 204 Bellevue, Washington 98004 425.739.4772 (phone) 425.739.4778 (fax) msargentphd@gmail.com Welcome to my practice! I