ADVANCE THRU PSYCHOTHERAPY & FAMILY DEVELOPMENT, PA

_____Tamara Sofair-Fisch, Ph.D. NJ Licensed Psychologist (#35S100165100)

_____Mark Sofair-Fisch, Ph.D., NJ Licensed Psychologist (#35S100432500)

NJ Licensed Clinical Alcohol and Drug Counselor (# 37LC00043500)

Location #1_______ Location #2______

2737 Princeton Pike 395 Pleasant Valley Way

Lawrenceville, NJ 08648 West Orange, NJ 07052

Ph: (609)883-2577 (973)669-3333

Fax:(609)883-2092 (973)669-9675

I. INFORMED CONSENT

This form summarizes our business practices, to which you are agreeing. Please read it carefully and ask any questions that may arise for you. Please initial the end of each section, indicating that you have read and understand that section. Once you are comfortable with what this agreement says, please sign the last page and return the form to me. Please feel free to request a copy for your records.

You have chosen to receive psychological and/or counseling services from the therapist whose name is checked above. Your choice has been voluntary and you understand that you may terminate these services at any time.

You understand that there is no assurance that you will feel better. Because psychotherapy is a cooperative effort between you and your psychologist, you will work with your therapist in a cooperative manner to resolve your difficulties.

You understand that during the course of your treatment, material may be discussed which will be upsetting in nature and this may be necessary to help you solve your problems.

You understand that records and information collected about you will be held and released in accordance with state laws regarding confidentiality and privilege of such records and information.

You understand that state and local laws require that a Psychologist report all cases of abuse or neglect of minors, and the existence of a clear danger to self or others.

You understand that the first session is known as a diagnostic evaluation. At this first session, we will discuss your presenting problems and complaints, history, previous therapy, medications, goals, etc. This thorough evaluation will permit your psychologist to create a treatment plan for you. Sometimes, the evaluation process takes more than one session. In all cases, the actual therapy sessions begin after the first session.

Initial__________ Initial__________

II. Fees

(1) Initial Psychological Evaluation $225 (3) Individual Psychotherapy $175

(2) Marital and/or Family Psychotherapy $195

Fees are structured differently for holders of Medicare and/or insurance plans with which we participate. We honor the fee structure imposed by these plans. This will be discussed at the time that we establish your initial evaluation appointment. Sometimes there is confusion as to whether or not we actually participate with your plan. It is your job to contact the insurance company and gather the details. If you have received incorrect information from the insurer, it is your job to deal with the insurance company, to rectify any errors.

It is your responsibility to notify your therapist of any changes to health insurance, immediately.

If your insurance company demands that we issue a refund to them for services they previously paid, you agree to reimburse your psychologist for these fees (example, your health insurance terminated. The company paid the fees, but then realized their error and demands a refund.).

Initial__________ Initial__________

III. For Couples or Family Therapy

We have chosen to receive psychological and/or counseling services from the therapist whose name is checked above. Our choice has been voluntary and we understand that we may terminate these services at any time. We are here to work on improving the emotional health of our family. Hence, we understand that our psychologist is committed to creating a safe environment where each of us feels free to share openly about our concerns and problems. We agree and understand that:

· It is not the job of the therapist to inform me of anything that my spouse might share with me.

· It is not the job of the therapist to take sides.

· In the event of any future legal actions, the therapist will not release any records unless both parties have signed authorizations permitting the release of the record.

· I authorize my psychologist to speak with my spouse about relevant issues without my presence. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

We understand that there is no assurance that we will feel better or that our relationship will improve. Because psychotherapy is a cooperative effort between me and my psychologist, I will work with my therapist in a cooperative manner to resolve my difficulties.

Not applicable______ Initial__________

Initial__________

IV. Payment

Payment is expected at the time services are rendered. We accept cash, checks or credit cards. Please inform us if financial difficulties arise, so that we may work out plans that permit you to receive your therapy without excessive hardship. Occasionally, we will agree to have you pay your portion, while we wait for the insurance check. Many insurance companies do not honor assignment, which means they send the check to you, and not to us. In such cases, you agree that you will bring the insurance check to us promptly.

If you fail to honor the payment obligations that we agree upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court, which will require us to disclose otherwise confidential information. In most collection situations, the only information released is your name, nature of service provided, and the amount due. The costs of any legal actions will be added to your fees.

There is a $25 fee for bounced checks. Fees that are unpaid for 90 days may be turned over to a collection agency.

Initial__________ Initial__________

V. Cancellation/Missed Session Policy

Late cancellations or missed appointments are charged at the full fee. We realize that occasionally, illnesses or emergencies occur that are beyond your control. Hence, we allow one missed/late cancellation session per year. Otherwise, you must provide us with 48 hour cancellation notice, or you must pay the full fee for your session. Your insurance will not pay for any of these charges.

We request that you complete a credit card form which we will hold in our file, which will permit us to charge you for the full amount of the session.

Initial__________ Initial__________

VI. Policies Regarding Phone and Email

We do not charge for time spent on the phone or email for the discussion of any procedural matters such as appointment schedules and issues regarding insurance companies.

We do charge for phone time spent on therapeutic issues, at the pro-rated rates listed above. Also, time spent communicating to others on your behalf, either by phone or in writing, is also charged accordingly.

We do not use E-mails as communication method for therapeutic issues, since emails are an unsecure form of communication.

Initial__________ Initial__________

VII. Insurance Billing

As a courtesy, we submit the insurance claims on your behalf, so that you receive reimbursement speedily. Claims are filed electronically, whenever possible.

Initial__________ Initial__________

VIII. Policies Regarding Insurance Companies

If I am planning to utilize my health insurance in order to make full or partial payment for psychological services, I understand that my insurance carrier may require certain information about me, my problems and my treatment be provided to them in the form of what are most commonly termed, “Out Patient Treatment Plans.” I understand that these “Treatment Plans” may be required for what is termed “Utilization Review”: A process whereby my insurance carrier determines whether additional psychological treatment is needed. I understand that the criteria most often used to make that determination is whether continued treatment is “Medically Necessitated.” In some cases, insurance carriers require “Discharge Summaries” to be submitted by the treating Psychologist at the end of treatment.

I understand that in all instances the name checked above will explain the requirements of my particular insurance carrier in this regard and obtain separate authorization from me for the release of such treatment plans.

I understand that I may refuse to release such information to my insurance carrier. However, if I do refuse, I understand that my insurance carrier will in all likelihood refuse to make payment for additional services. I have the right to continue in treatment at my own expense.

I understand that in situations wherein my health insurance is of the kind known as an “Indemnity plan,” there may also be need for such disclosure regarding of my treatment. If I choose to submit claims to my insurance carrier under this type of plan, or if I ask my Psychologist to submit such claims on my behalf, these claims will contain the necessary identifying information, the dates of service (e.g., individual psychotherapy, psychological testing), a fee for that service and a diagnostic code.

Initial__________ Initial__________

IX. The Health Insurance Portability and Accountability Act (HIPPAA)

The Health Insurance Portability and Accountability Act (HIPPAA) is a Federal Law that has been implemented to protect health services consumers. The provisions of this law, as privacy, confidentiality, content disclosure and reporting, are congruent with state laws already carried out by this practice. These policies will continue and are also required by HIPPA. The privacy of your health information is protected by appropriate procedures and policies, such as coding for identity concealment, as well as following official rules of consent and disclosure. For example, your records are available to you but disclosed to others only with your permission, unless disclosure is required by law. Also, there is protection of your confidential information by keeping records in secure places. Cooperation will be extended in the appropriate processing and transmission of forms, such as the provision of correct procedural and diagnostic codes. Essentially, as in the past, you will receive the protection of the rules of privacy, security, and transaction as currently mandated by HIPPA.

Please sign this form to indicate that you have received the information in sections I through VIII and that you understand your rights as a recipient of health services under HIPPA guidelines.

Signature of Patient #1 _______________________________________________

Signature of Parent, if Patient is a minor________________________________

Signature of patient #2 ________________________________________________

Date ___________________________________________________________

_____PATIENT                                                                   SPOUSE OR PARENT

_____________________________<NAME>___________________________

______________________<SOCIAL SECURITY #>_____________________

________________________<DATE OF BIRTH>_______________________

________________________<Driver’s LICENSE>______________________

________________________<HOME ADDRESS>_______________________

________________________________________________________________

________________________<HOME PHONE>________________________

________________________<WORK PHONE>_________________________

_________________________<CELL PHONE>________________________

_______________________<E-MAIL ADDRESS>_______________________

_______________________<EMPLOYER NAME>_______________________

_______________________<WORK ADDRESS>_______________________

________________________________________________________________

___________________<NAME OF INSURANCE PLAN>__________________

_________________<INSURED SUBSCRIBER NAME>___________________

___________________<ID#, IF DIFFERENT THAN SS#>________________

___________________________<GROUP #>___________________________

________________________<INS PHONE #>__________________________

__________________________<INS ADDRESS> _______________________

_________________________________________________________

EMERGENCY CONTACT__________________________PHONE #_______________________

RELATIONSHIP TO PATIENT______________________PHONE #_________________________

PHYSICIAN _______PRIOR THERAPIST

__________________________________<NAME>_________________________________

__________________________________<ADDRESS>_________________________________

______________________________________________________________________________

___________________________________<PHONE#>_________________________________

MAY I LEAVE A MESSAGE AT YOUR HOME ASKING YOU TO CALL ME?   YES____NO____

MAY I LEAVE A MESSAGE AT YOUR JOB ASKING YOU TO CALL ME?       YES____NO____

DO YOU WISH ME TO LEAVE MY FIRST NAME ONLY?                    YES____NO____

REFERRED BY__________________________________PHONE #______________________

ADDRESS___________________________________________________________________

PERMISSION TO THANK REFERRAL SOURCE?_____YES_____NO

PLEASE ASSIST US IN TRACKING HOW REFERRALS

ARRIVE TO OUR OFFICE

How did you learn about us?

_____A friend

_____My physician

_____A former patient of ours

_____NJ Psychological Association Referral Service

_____The Internet

_____My Health Insurance Provider List

_______Aetna

______Magellan

______Medicare

______Value Options

_____National Register of Psychological Providers

_____Yellow Pages

I SEARCHED UNDER THIS HEADING (PLEASE CHECK ONE)

_____MARRIAGE & FAMILY

______PSYCHOLOGIST

_____MENTAL HEALTH

_____ADDICTIONS

I used this book:

_____Verizon

_____Yellow Book

_____Orange, NJ

_____Montclair, NJ

_____Trenton, NJ

_____Princeton, NJ

I  SEARCHED USING THE INTERNET,

WHICH SITE DID YOU USE TO GET OUR CONTACT INFO?

_______ NATIONAL REGISTER FOR PSYCHOLOGICAL PROVIDERS

_______OUR SITE, www.EmotionalSolutions.net

_______GOOGLE LOCAL LISTING

_______OTHER (PLEASE SPECIFY)_____________________________________________________

I FOUND YOUR CONTACT PAGE BY SEARCHING WITH THE FOLLOWING KEYWORDS:

_____Superpages.com

_____Psychology.com

_____PsychologyToday.com

_____Psychologist in NJ

_____Psychologists in West Orange, NJ

_____Psychologists in Essex County, NJ

_____Psychologists in Lawrenceville, NJ

_____Psychologists in Mercer County, NJ

OTHER___________________________________________________

Thank you so much!

www.emotionalsolutions.net

_____Tamara Sofair-Fisch, Ph.D.          Clinical Psychologist- NJ lic #35S100165100

_____Mark Sofair-Fisch, Ph.D.,             Clinical Psychologist- NJ Lic # #35S100432500

NJ Licensed Clinical Alcohol and Drug Counselor #37LC00043500

Location #1_______                                                                             Location #2______

2737 Princeton Pike                                                                             395 Pleasant Valley Way

Lawrenceville, NJ 08648 West Orange, NJ 07052

Ph:  (609)883-2577                                                                    (973)669-3333

SIGNATURE FOR BILLING

• I authorize release of this form on all my insurance submissions.

• I authorize release of information to all my insurance carriers.

• I understand that I am responsible for checking the details of my coverage with my insurance carrier.  If preauthorization is required, it is my responsibility to ensure that preauthorization has been completed.

• I understand that I am responsible for my bill.

• I authorize payment to my doctor to act as my agent in helping me obtain payment from my insurance company.

• I authorize payment directly to my doctor.

• I permit a copy of this authorization to be used instead of an original.

Name (print)_________________________________________________

Signature___________________________________________________

Date:_______________________________________________________