Consent to treatment and payment authorization - Insight Psychological Group, Westfield-Maywood-Teaneck, New Jersey

Patient Information

Patient Name *

First

Last

Patient Date of Birth *//

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Credit/Debit Card Information

IPG processes payments using only cashless, electronic methods, even when treatment occurs in-person. As such, in order to reserve appointments with our therapists, IPG requires all clients to keep a valid credit/debit card securely stored on file with our Billing Department. Therapy is a weekly process, which is continuously billed to you or your insurance, generating ongoing cost-sharing balances. To keep this process as smooth as possible, our Billing Department seamlessly charges your card your ongoing balances as they become due. You can change the card kept on file at any time. You may also make alternative payment arrangements through our Billing Department.

Cardholder's Name *

Credit/Debit Card Type *

Credit/Debit Card # *

Expiration Date *

CVV2 Code *

Billing Address of Card *

Same as the patient's address
Different Address

Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Authorizations and Consent to Treatment

All boxes are required in order to submit form.

Authorizations *

I have had the opportunity to ask questions about the policies and procedures of IPG, as well as about the pros and cons of receiving psychotherapy. I agree to comply with these rules and conditions, and I understand that non-compliance with them will make my treatment subject to termination. My signature below represents my authorization to partake of treatment at IPG. I understand I have a right to withdraw my consent at any time in writing.

1 *

I understand that if my services are provided via telehealth, there are inherent risks including interruptions, unauthorized access, and technical difficulties, as well as increased challenges should a crisis or emergency arise. I will not hold IPG responsible for the technological problems it has no control over. I understand that if I or my child demonstrates an exacerbation of symptoms, or if I do not follow the above rules for telehealth services, telehealth sessions may be discontinued, and in-person treatment or a referral to a higher level of care may be necessary. In such circumstances, if IPG cannot provide in-person treatment, a referral will be made to another practice.

2 *

I understand that IPG will need to share confidential information with third parties, such as my insurance carrier(s), in order to authorize and reimburse my sessions. These third parties may have a right to review my treatment at any time. My signature below also authorizes the release of this information in order to process my sessions, and for payment to be made directly to IPG for services rendered.

3 *

I understand that I am ultimately financially responsible for my treatment services at IPG to pay any balances owed after all third-party payments have been applied, or should any third-party payer decline to pay for some or all of my treatment. I understand that IPG reserves the right to send any delinquent balances and accounts to a collections agency with whom I may not have any previous relationship. I may be billed additional fees associated with the collection of my balance.

4 *

I have had the opportunity to review and ask questions regarding IPG’s Notice of Policies and Practices to Protect the Privacy of Your Health Information, and I understand my rights as a patient.

5 *

With my signature below, I authorize the use of the above card to be charged all assigned fees, copays, coinsurance amounts, deductibles, Scheduling Fees for appointments not kept, or any amounts due as determined by my insurance, for the patient listed above. By signing this payment authorization form, I certify that I am authorized to agree to the above terms on behalf of the patient listed, and to authorize the use of this card.

Signature *

Date *

Name of person signing *

First

Last

Relationship to Patient *

Self
Parent/Guardian
Spouse
Other

Phone *

In case we need to reach out to you with any questions

Email *

For emailed copy of this form

Therapists Email *

Select your therapist's email in order to have them receive an automatic notification that you have completed this form.

CONSENT TO TREATMENT AND PAYMENT AUTHORIZATION FORM

Patient Information

Credit/Debit Card Information

Authorizations and Consent to Treatment

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