POLICIES OF THE ASSESSMENT CENTER AT OAK HILL ACADEMY

9407 Midway Road Dallas, Texas 75220 Phone: 214-353-9323 Fax: 214-239-2958 POLICIES OF THE ASSESSMENT CENTER AT OAK HILL ACADEMY This document contains information about the Assessment Center at Oak Hill Academy and its business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA). Although this document is long and sometimes complex, it is very important that you read it carefully. We can discuss any questions you have about the procedures and fees. When you sign that you have read this document, it will represent an agreement between us. You may revoke this agreement in writing at any time. That revocation will be binding on me unless we have taken action in reliance on it, or if you have not satisfied any financial obligations you have incurred. PSYCHOEDUCATIONAL EVALUATION A psychoeducational evaluation is performed in order to determine if there is an academic, attentional, behavioral, or emotional issue that may be impacting performance in an academic setting or at home. A typical evaluation involves a parent interview or interview with adult client, consultation with teacher(s), and intellectual, academic, attentional, and behavioral testing. Emotional functioning is screened and more thorough psychological testing may be recommended. Approximately three weeks after the testing, a feedback is conducted and usually the comprehensive written report is provided at this time, along with a PDF version sent via email. The cost of the evaluation is $1,900.00. Additional services such as a classroom observation prior to testing or meeting at the school for feedback over the test results will be billed at hourly rate of $200.00. Although no two evaluations are alike, these basic parameters provide a description of what is included as part of the evaluation fee. Background information o Through written completion of a packet and a phone interview with parent (approx. 30 minutes) o Consultation with teacher/professional (when available) (approx. 30 minutes) Psychological testing of student (maximum of 7 hours; range is from 5 7 hours due to breaks provided student and rate of student s response). Testing includes: o Behavioral observations o Wechsler Intelligence Scale for Children - 5 th Edition (WISC-V) or Wechsler Adult Intelligence Scale 4 th Edition (WAIS-IV) tests of intellectual functioning (full scale IQ, verbal comprehension, perceptual reasoning, working memory, and processing speed) o Woodcock-Johnson Tests of Achievement & Tests of Oral Language 4 th Edition (WJ-IV): tests of academic achievement (total achievement, skills, fluency, reading, written and oral language, math, etc.) o Behavior Assessment System for Children 3 rd Edition (BASC-3): behavioral & emotional functioning scales (also obtain ratings by parents and teachers)

o Various other tests depending upon the reason(s) for referral for the testing --- may include: CTOPP-2 (Comprehensive Test of Phonological Processing 2 nd Edition) GORT-5 (Gray Oral Reading Tests - 5 th Edition) GSRT (Gray Silent Reading Tests) Nelson-Denny Reading Test (high school and college students) TOWL-4 (Test of Written Language 4th Edition) CVLT-C (California Verbal Learning Test - Children s Version) Beery VMI 6 th Edition (Beery-Buktenica Developmental Test of Visual Motor Integration, Visual Perception, and Motor Coordination) IVA-2 CPT (Integrated Visual & Auditory 2 Continuous Performance Test) Brown ADD Scale CDI 2 (Children s Depression Inventory 2 nd Edition) MASC-2 (Multidimensional Anxiety Scale for Children 2 nd Edition) Roberts-2 (Roberts Apperception Test for Children 2 nd Edition) CELF-5 Screening Test (Clinical Evaluation of Language Fundamentals 5 th Edition Screening Test) ASIEP-3 (Autism Screening Instrument for Educational Planning 3 rd Edition) Written report (hours not specified) Feedback with parents (approx. 1 hour) PROFESSIONALS Director: Suzanne Eades, Ph.D., L.P., LSSP ~ Dr. Eades is a Licensed Psychologist, Licensed Specialist in School Psychology, and former Certified Academic Language Therapist, school counselor, and classroom teacher. Dr. Eades specializes in psychoeducational testing, counseling, and social skills training for school age children through adults. Associates: Lorelei Simpson Rowe, Ph.D. ~ Dr. Rowe is a Licensed Psychologist and is on the faculty of the Psychology Department of Southern Methodist University. She conducts research on family relationships, with a focus on violence prevention and coping with mental illness. Dr. Rowe specializes in psychoeducational testing for children, adolescents, and adults. Lisa Partridge ~ Ms. Partridge is the Administrator for the Assessment Center and Speech-Language Clinic. She welcomes all visitors to the center and handles scheduling and billing questions. CONTACTING US Due to our work schedule, we are often not immediately available by telephone but will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform us of the times that you will be available. Email is also a productive method in which to reach us. FEES The cost of the evaluation is $1,900.00, and the balance is due the day of the evaluation. In rare occasions, additional fees apply if the evaluation exceeds the parameters discussed above, which will be billed at the hourly rate. These may relate to multiple parent interviews, consultations with multiple professionals, testing that exceeds seven hours, additional communications after the feedback, etc. Before conducting these services, we 2

will discuss these with you. A non-refundable deposit of $300.00 is required at the time of booking the assessment, which is credited toward the $1,900.00 fee. If the evaluation is canceled prior to 10 business days before the testing date, $100.00 will be reimbursed. If the evaluation is cancelled within 10 business days of the assessment, the deposit is forfeited. If the evaluation is rescheduled prior to 5 days of the testing date, the deposit will be credited toward the evaluation. If the evaluation is rescheduled within 5 business days of the assessment, the deposit is forfeited; in case of illness, exceptions to this policy can be discussed. The rescheduled evaluation, however, must occur within 90 days of the originally scheduled assessment or another deposit is required. If the rescheduled evaluation is cancelled, the deposit is forfeited. Since both a hard copy and a PDF version of the report are provided, a $20 records fee is charged for providing an additional copy of the report after six months of the date the evaluation was conducted. PROFESSIONAL FEES Dr. Eades and Dr. Rowe charge an hourly fee of $200.00 for psychological services. If services are required beyond the evaluation, we will break down the hourly cost if we work for periods of less than one hour. Other services that we reserve the right to bill for include telephone conversations lasting longer than 5 minutes, emails exceeding 5 minutes to reply, consulting with other professionals with your permission, and the time spent performing any other service you may request of us. If you become involved in legal proceedings that require our participation, you may be expected to pay for all of our professional time, including preparation and transportation costs, even if we are called to testify by another party. We will accept pre-arranged confirmation of payment by the law firm requesting deposition. However, if the attorneys do not pay for our time, we will expect you to compensate us. Because of the difficulty of legal involvement, we charge $300.00 per hour for preparation and attendance at any legal proceeding. INSURANCE REIMBURSEMENT We do not accept insurance and do not complete any forms from insurance companies. In addition to the comprehensive written report, at the feedback you are provided a receipt of services that includes necessary information for insurance companies. In the event that we receive a request from an insurance company for more information, we will forward that request to you. Again, we do not handle insurance matters. You may also need to contact the Human Resource department of the subscriber s employer for assistance in filing your claim. PROFESSIONAL RECORDS The laws and standards of our profession require that we maintain accurate and pertinent records, which are kept in a manner that protects confidentiality. Release of information about a client is only provided if you give written authorization to release the record to a specific person/entity, and you must revoke the release in writing if you change your mind. For example, if you provide us with a release to provide your confidential information to a physician or another healthcare provider, and then later decide to change providers, you will need to revoke the original authorization in writing. You should be aware that pursuant to Texas law, psychoeducational test data and protocols are not part of a client s record. Records and test data will be maintained seven years from the date of the evaluation. If the client is a minor, the record period is extended until three years after the age of majority. Again, if a copy of the psychoeducational report is requested after six months from the date the evaluation was conducted, a $20 records fee is charged. A copying fee of $0.75 per page is made for copying other parts of the record (e.g., the summary of charges). LIMITS ON CONFIDENTIALITY The law protects the privacy of clients, and the release of the psychoeducational evaluation and related records is restricted unless you provide written authorization to release the record. There are certain situations that do not require your consent. Following are some of those examples. It is our practice to provide you with prior notice of the primary examples. Your signature on this agreement confirms your understanding that we do not 3

need your consent in these types of situations. We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, we make every effort to avoid revealing the identity of our client. The other professionals are also legally bound to keep the information confidential. If you do not object, we will not tell you about these consultations unless we feel that it is important to our work together. You should be aware that we practice with other mental health professionals and that we employ administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, and quality assurance. All of the mental health professionals and administrative staff are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. If a patient threatens to harm himself/herself, we are obligated to contact family members or others who can help provide protection. There are some situations where we are permitted or required to disclose information without either your consent or authorization: If you are involved in a court proceeding and a request is made for information concerning your diagnosis, such information is protected by the therapist-patient privilege law. However, we may be required to provide information with your (or your legal representative's) written authorization, a valid subpoena, 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 information to be disclosed. If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves. There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a patient s treatment. These situations are extremely unusual in our practice. If we have cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that we make a report to the appropriate governmental agency, usually the Department of Protective and Regulatory Services. Once such report is filed, we may be required to provide additional information. If we determine that there is a probability that the client will inflict imminent physical injury on another, or that the client will inflict imminent physical, mental or emotional harm upon him/herself, or others, we may be required to take protective action by disclosing information to medical or law enforcement personnel. If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary. This summary of exceptions to confidentiality is not exhaustive. PATIENT RIGHTS HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and health care operations. The Notice, which is attached to this agreement, explains HIPAA and its application to your personal health information in greater detail. HIPAA also provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the Notice form, and our privacy policies and procedures. The law requires that we obtain your signature acknowledging that we have provided you with this information. 4

Notice of Psychologists Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I. Uses and Disclosures for Treatment, Payment, and Health Care Operations I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions: PHI refers to information in your health record that could identify you. Treatment, Payment and Health Care Operations Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist. - Payment is when I provide a receipt of services. - Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. Use applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. Disclosure applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties. II. Uses and Disclosures Requiring Authorization I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. Psychotherapy notes are notes I have made about our conversation during a private or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy. III. Uses and Disclosures with Neither Consent nor Authorization I may use or disclose PHI without your consent or authorization in the following circumstances: Child Abuse: If I have cause to believe that a child has been, or may be, abused, neglected, or sexually abused, I must make a report of such within 48 hours to the Texas Department of Protective and Regulatory Services, the Texas Youth Commission, or to any local or state law enforcement agency. Adult and Domestic Abuse: If I have cause to believe that an elderly or disabled person is in a state of abuse, neglect, or exploitation, I must immediately report such to the Department of Protective and Regulatory Services. Health Oversight: If a complaint is filed against me with the State Board of Examiners of Psychologists, they have the authority to subpoena confidential mental health information from me relevant to that complaint. Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is 5

made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information, without written authorization from you or your personal or legally appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case. Serious Threat to Health or Safety: If I determine that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, I may disclose relevant confidential mental health information to medical or law enforcement personnel. Worker s Compensation: If you file a worker's compensation claim, I may disclose records relating to your diagnosis and treatment to your employer s insurance carrier. IV. Patient's Rights and Psychologist's Duties Patient s Rights: Right to Request Restrictions You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.) Right to Inspect and Copy You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process. Right to Amend You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process. Right to an Accounting You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process. Right to a Paper Copy You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically. Psychologist s Duties: I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. V. Complaints If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact The Texas State Board of Psychological Examiners. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request. VI. Effective Date, Restrictions and Changes to Privacy Policy This notice will go into effect on 12/11/15. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. 6