Jayme Yodice, MA 1905 J.N. Pease Place Suite 104 Licensed Psychological Associate Charlotte, NC 28262 NC 2390 704-609-3614 Psychological Testing Fees and Consent for Services Welcome! Psychological testing can provide valuable information to help you make decisions regarding educational needs, to clarify a more accurate diagnosis/ diagnoses or to help provide recommendations for treatment. Psychological testing services are different from therapy services. Usually, there is an intake session where information is gathered about what the testing needs are and background information is obtained if needed. Testing sessions vary from 1-5 sessions depending on the needs. Sessions can range from 1 hour to up to 3 hours. I make every effort to keep testing session lengths reasonable so that clients are not fatigued which could impact their performance. Thus, this can result in an increased number of sessions. Fees: Because I value our relationship with you and believe that the best relationships are based on understanding, I offer these clarifications on payment and cancellations. Please see separate statement about BCBS and insurance for psychological testing. $120 for initial appointment (intake session) $120 per hour for testing (for every face to face hour, there is an additional hour of billing for test scoring, report writing, editing of reports, as well as cost of tests and test materials) $100 for a one-hour parent feedback of psychological test results -IQ test only (WISC-V or WPPSI-IV): $300 per testing including write-up. This usually occurs in 1, 2-3 hour session -Achievement Test only (Woodcock Johnson Test of Achievement IV): $300 per testing including write-up. This usually occurs in 1, 2-3 hour session -Psycho-educational battery and full report with recommendations: This battery includes an IQ test, achievement test, diagnostic interviewing, a full report with recommendations and a feedback session. $900 -Pre-K testing (to determine if child meets criteria for possible early admission to Kindergarten). This includes IQ and Achievement testing. The Full cost is $500.00. This does not include a feedback session. -ADHD Testing: This battery can include a variety of testing measures depending on current needs. If no recent IQ or Achievement measures have been given, they will be included in this evaluation. Sometimes extended achievement testing is not needed to do an ADHD evaluation and unnecessary testing will not be given in order to keep costs down for clients. This evaluation can include but is not limited to: -IQ -Achievement -Conners-3 and other self-report measures
-Self report measures to identify any co-occurring issues such as anxiety or depression -Additional tests to measure processing speed, visual-motor skills -observation of client s behavior in the office OR at school if needed (additional fees may be included) -Full report with all results and recommendations -Feedback session to review ALL results, recommendations, and if agreed with written consent, information can be faxed to client s school. -Cost: A typical comprehensive evaluation for ADHD will range between $1200 and $1400 depending on which measures are needed. Additional costs may be accrued if you request that I do school observations or review multiple previous evaluations or records. These fees will be discussed up-front and agreed upon in writing. -Psychological Evaluations (which may include any of the above) this evaluation is used when mental health/ diagnoses are the primary questions. This type of evaluation may also include IQ, Achievement, Measures to assess for ADHD mentioned above, personality tests such as the PAI or MMPI, other self-report measures, in depth diagnostic interviewing with client and/ or multiple sources with client consent, review of records, consultation with medical providers if client has co-occurring medical issues. Cost: $1500 (cost can be minimized if some testing measures are not needed). Additional costs may be accrued if you request that I do school observations or review multiple previous evaluations or records. These fees will be discussed up-front and agreed upon in writing. Evaluation for Lap-band/ Gastric Bypass Surgeries: Making the decision to undergo extensive surgery for weight loss is an important one. Surgeons require a psychological evaluation to ensure the patient is emotionally ready for surgery, understands the behavioral/ lifestyle changes that must be made now and after surgery and also to offer supportive counseling to those who may need it. Jayme Yodice, LPA is not a medical doctor and therefore does not give medical advice. An evaluation for this purpose by Jayme Yodice consists of a clinical interview to ask about current health and eating behaviors, the administration of several self-report measures to further assess for depression, anxiety or other concerns, feedback with recommendations on how the patient can best cope with surgery and the expectations afterward. Jayme Yodice can also be available to provide therapy if needed for patients who need that extra support and motivation. Evaluation costs vary but typically range from $250-500. Some insurance may cover a portion of the evaluation, and some may not. A fee of $100 is collected upfront, insurance is then billed and any amount not covered is due before results are given to the patient. Gestational Carrier Candidates Psychological Evaluation: A psychological evaluation for a gestational carrier candidate involves a clinical interview and completion of the Personality Assessment Inventory (PAI) for the carrier candidate and their partner if applicable. Clinical interviews may also be required for the intended parents and some fertility clinics also require that all parties involved (both couples) have a full psychological (clinical interview and personality inventory). This may include partners and spouses. The cost of the evaluation range from $260 for the gestational carrier candidate alone, to $800 for evaluations for the entire group (assuming there are 4 in the group). The fee includes time spent face-to-face in the office and time for the psychologist to score, interpret the PAI and assimilate all the information into a report. Insurance does not cover this service. Payment is due at the first appointment. Most sessions are 60-90 minutes per individual including time to complete the PAI. Followup reports are usually completed with 2-3 weeks of the last appointment completed for the entire group. All parties involved must sign Consent For Release forms allowing all involved access to the information in the report, as well as any agency requesting the information. Special note about fees for psychological testing: Insurances vary with whether or not they cover psychological testing and often require pre-authorization and do not cover the hours needed. If I am in network for your insurance (BCBS only), I will file for the initial session, testing sessions and follow-up sessions. Applicable co-pays are due at each session. If out of network, half the FULL testing fee is due at
the first testing session with subsequent payments broken down in future sessions and full payment is due prior to receiving testing results (including reports, feedback sessions, or requesting me to send results to a third party). If I am out of network, full rates are due and broken up over sessions as outlined above or as agreed upon noted on the signature page of this form. This also applies to clients for whom I am in network but the client has deductibles. I will provide receipts for testing services if clients wish to seek reimbursement on their own. My fee remains the same regardless of whether or not insurance reimburses you. If you have BCBS and for some reason they deny testing services or it is not covered under your plan, you will owe FULL psychological testing fees. PLEASE SEE NOTICE ABOUT BCBS Release of Information: In addition, testing results cannot be released without your specific written consent (see my privacy policies for more information). By signing below, I acknowledge primary responsibility for the payment of services to Jayme Yodice, LPA. I request that if I have been informed that my insurance will cover testing, Jayme Yodice, LPA will seek reimbursement and is permitted to release psychological information to the insurance carrier, or case manager, when the information is requested to process claims. I do not object to this information being released by mail, fax or phone. If Jayme Yodice is out of network or testing is not covered, Jayme Yodice will provide you with a receipt of services received and fees paid so that you can seek reimbursement on your own. Confidentiality and Privacy Notices The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain requirements imposed by HIPPA. See our Notice of Privacy Practices for more information. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities as follows: I am required by the NC Psychology Board to meet regularly with a Licensed Psychologist for consultation and supervision. This is to ensure I am providing the best care to clients and to seek consultation when needed. During these meetings, I make every effort to avoid revealing the identity of my clients and the psychologist I meet with is also legally bound to keep the information confidential. I will note all consultations in your clinical record (which is called PHI in my Notices of Privacy Practices). Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this agreement. If I believe that a client presents an imminent danger to his/her health or safety, I may be obligated to seek hospitalized for her/her or to contact family members or others who can help provide protection. By state law, there are certain exceptions to confidentiality that you should be aware of: 1) If you threaten to harm or kill yourself or another person, I am legally and ethically required to take action to protect the safety of the threatened person. Possible actions could include informed the intended victim, arranging for your hospitalization, notifying family or support system or alerting law enforcement. 2) If I know or suspect abuse or neglect of a child, an elder person or a disabled person, I am required to report my concerns to County Department of Social Services. 3) If you are involved in a court proceeding and a request is made for information concerning the professional services that I have provided you, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your written authorization, or a court order. If you
are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. 4) If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. 5) If a patient files a worker s compensation claim, and my services are being compensated through worker s compensation benefits, I must, upon appropriate request, provide a copy of the patient s record to the patient s employer or the North Carolina Industrial Commission. 6) If you name me in a lawsuit, the law states that I can, and sometimes am obligated to reveal information that would otherwise be confidential or order to defend myself. If such situations arise, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. 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 have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. Professional Records The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in your Clinical Record. You may examine or receive a copy of your record if you request it in writing. Because these are professional records, they can be misinterpreted and/ or upsetting to untrained readers; therefore, I recommend you initially review them in my presence or have them forwarded to another mental health professional so you can discuss the contents. I am allowed to charge a copying fee per page. If I refuse your request for access to your records, you have a right to a review, which I will discuss with you upon request. Patient Rights You have now been given a copy of the Notice of Privacy Practices and been given an opportunity to discuss any questions that you have. This notice is also displayed in my office lobby area if you should ever want to review it. By signing at the end of this Consent for Treatment, you are confirming that you have received a copy. Cancellations I require 48-hours-notice if you need to cancel/ re-schedule a psychological testing appointment. When psychological testing session are scheduled, 2-4 hours of my time are set aside specifically for you. Therefore if you do not give me 48-hours-notice for re-scheduling, I charge a fee of $40 per hour (if 2 hours were blocked for testing, this fee would be $80). Exceptions to this are when emergencies arise and you should contact me when you are able to re-schedule. If missed appointments or frequent re-scheduling occurs, this can result in termination of psychological testing services.
Signature Page and Consent for Psychological Testing Services After discussing the evaluations being offered, I have decided to choose at a rate of. I understand that half the FULL fee is due at the first session which may be today and we have agreed at the following additional payment arrangement: due at session 2 due at session 3 -Payment in full due by: Regarding refunds: We do not offer refunds if you are unhappy with the evaluation, report, clinical suggestions or recommendations; we do not offer refunds if your insurance company refuses reimbursement of our services; we do not offer refunds under any circumstances. YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS DOCUMENT AND YOU HAVE BEEN PROVIDED A COPY OF OUR PRIVACY PRACTICES, AND AGREE TO ABIDE BY THESE TERMS DURING OUR PROFESSIONAL RELATIONSHIP. Please sign and date below to indicate that you have read the preceding information in full, and understand the information. Please ask for clarification of any information you are unclear about. I agree to the statements herein and the terms of payment. Client: / / (Signature) (Printed Name) (Date Signed) psychologist: / / (Signature) (Printed Name) (Date Signed)