Dr. Todd Snyder, Psy.D., H.S.P.P.

Welcome to our practice! We appreciate the support and confidence you, and those who referred you, have shown by selecting this practice. Please read the following information carefully and retain a copy as it contains the answers to some commonly asked questions as well as your consent for us to provide services and the terms of agreement by which we will work together and to which we agree. Your doctor and I welcome your feedback and encourage open communication between doctor and patient.

THIS NOTICE DESCRIBES OUR POLICIES AND PROCEDURES AFTER HOURS & EMERGIENCIES:

We do not carry pagers and do not provide after hours access or services. In the event of an emergency call 9-1-1. However, if you are in a true emergency situation, you may attempt to contact me on the cell phone that I keep with me by calling 866-300-8116 and following the instructions for emergency situations. If you call me, do not wait for a return call before taking action to seek help by dialing 911 or asking someone to accompany you to the nearest emergency room. 

FEES FOR CONSULTATION OR CORRESPONDENCE OUTSIDE OF SCHEDULED APPOINTMENTS:

At times, some clients find significant value in seeking short consultations over the phone or by email between sessions. Any phone consultation or email requiring more than five minutes for response will be billed at the usual professional consultation fee, at $25 per 15 minutes, with a baseline fee of $10 for any consultation exceeding five minutes. Likewise, any phone calls, written correspondence with physicians, attorneys, school personnel, or others that you request will be billed according to the $25 per 15 minute rate with the $10 base rate per document or consultation.

APPOINTMENT CHANGES:

Late cancellation of appointments are disruptive to treatment. Late cancellation also interferes with the doctor's ability to make a living because the slot cannot be filled by someone else on last minute notice. Please notify us at least two business days in advance if you must cancel or change your appointment time. Otherwise, by signing this form, you agree to pay for missed appointments or late cancellations (less than 48 hours) with a $25 fee.

Session Length:

Sessions are 45-minutes in length unless otherwise specified in advance. Please note that your doctor needs to maintain 45-minute sessions unless your fee covers a longer period of time such as the 80 minute couple's counseling sessions.

QUALITY OF CARE:

It is important that you receive the highest quality of care. Toward this end, it is essential that you and your clinician communicate openly and freely about the services you are receiving. Please do not hesitate to share your concerns, as well as your successes, with your clinician.

AUTHORIZTION TO TREAT & DISCHARGE

Your signature below constitutes your request that your doctor and this practice provide clinical services to you or the patient in your charge. Each time you make or keep an appointment you are authorizing us to continue with the procedures we have planned for you. By the same token, by missing an appointment or not scheduling an appointment you will be authorizing your provider to discharge you from this practice. Unless superseded by an agreement documented in your chart, an administrative discharge will automatically occur 45 days after our last face-to- face contact with you.

CONFIDENTIALITY:

All communication between you and your clinician are confidential. Indiana law does, however, specify some exceptions including interventions when you are in danger, a danger, your health is declining, or upon the order of a judge. In the interest of quality of care, we will send a summary and recommendations to any professional who has referred you unless you write to us to revoke this permission. If we bill your insurance on your behalf, you agree that we may release any and all information requested by your insurance company. If you write checks or use credit cards, a minimal amount of protected health information (i.e., name and dates) will be released for billing purposes. Otherwise, no information will be released without your additional written consent. By accepting services at this office you are agreeing to also grant your doctor the privilege of confidentiality.

FEES:

Unless otherwise agreed in advance, all fees are due at the time of service. Most of the services we provide are billed on a 45-min session. Please feel free to inquire about changes in advance. By signing this form, you agree to be responsible for payment of all fees. By signing this form, you agree to accept responsibility for notifying Todd Snyder, Psy.D., H.S.P.P. if you feel a refund is due or if an error in billing and/or collections has occurred. Our efforts to work with your insurance company do not alter your responsibility for fees. Visa and MasterCard are accepted for diagnostic procedures and fee-for-service procedures only.

INSURANCE, MEDICARE, AND PPO'S:

Unless special arrangements have been made in advance, you agree to pay all fees at the time services are rendered. In order to better serve you, we will be happy to bill your insurance for you. If you are insured under a preferred provider agreement, you agree to pay the coinsurance and/or deductible amount(s) at the time services are rendered. If you are insured by Medicare or Medicaid, we will accept Medicare assignment. You agree to pay the coinsurance amount and any deductible amount at the time of service. 2

FINANCIAL AGREEMENTS:

Even when we bill your insurance in your behalf, you agree to remain responsible for your bill. Due to changes in the American healthcare system, it has become necessary for a finance charge to be charged on all past due accounts. By signing this form, you agree to pay a finance charge of 18% per year beginning six weeks after services were rendered.

LEGAL EXPERT SERVICES:

Do not sign this form if you are seeking, or might ever want to seek any legal expert or other forensic service in this office. To avoid ethical dilemmas and to ensure a clear focus on your clinical needs, your signature below indicates that you agree not to involve your record, this office, or any of our employees, in any legal issues in which you are a party. If you are specifically seeking consultation in order to obtain records or expert testimony for legal purposes, then please discuss your interests with your clinician and complete a separate written agreement for forensic services. Unless otherwise agreed in advance, the fees for such services begin at $300/hour. Insurance cannot be used to pay for these services.

CO-PAYMENTS FOR TESTING?

Most insurance policies call for one co-pay per office visit. Since test procedures involve multiple units of service this causes a problem which insurance companies have consistently refused to address. The problem is, either the patient has to make many trips to the office in order to complete the entire test battery, or the doctor has to write-off the costs of that portion of the fee. Alternatively, you can save yourself the trips and pay all of the co-pays in the same day at no additional cost to you. For example, if your co-pay is $10.00 and you will be taking 6 units of testing, you would pay $60.00 (Just as you would if you choose to return 6 times). If you do not wish to do this, feel free to cross out this paragraph before agreeing to these terms of service by signing this form on the last page.

SOME THINGS TO KNOW ABOUT MANAGED CARE

Many of our patients choose not to use health insurance to pay for their treatment, because managed care removes the power to choose what treatments will be available to you and for how long. By electing to use your managed health insurance plan you are electing to allow the terms of your policy to determine your access to various treatments, the amount of treatment you receive, your access to diagnostic procedures, and the level of confidentiality.

Managed care companies earn their money by controlling the amounts your insurance company pays out in claims. Some insurance companies have taken to sending authorization letters that suggest they will cover a service and/or a diagnosis but there is a catch or 'backdoor" by which they can change their mind after those services are rendered. All too often they use that 'backdoor" to deprive the doctors of payment; therefore, unless we receive an unequivocal letter of authorization you will be responsible for payment of fees at the time services are rendered. Often insurance companies tell their insured's that a certain service or diagnosis is covered. They do not always mention that this is only the case under certain conditions. For example, family therapy is often a covered service if it is being used for the treatment of a severe psychotic illness but it is rarely a covered service when it is used for its' more common purpose of treating problems in a marriage.

In managed care parlance the term "not medically necessary" has come to mean "not covered by the policy that was purchased." The term "usual and customary fees" has come to mean the fees the insurance company sees as reasonable, regardless of what the norm is in the community.

Problems in school, marital conflicts, personal growth and development, disease prevention, and longstanding issues are among the issues that people often want to address but which are seldom covered under managed care. To forgo managed care puts you and your doctor back in charge. Cross out the insurance information on your intake form to indicate that you do not want to be restricted by your insurance..

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED

AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Effective date: April 1, 2003

If you consent, the provider is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, test results, diagnosis, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of uses of your health information for treatment purposes are: