Hello. I am happy to begin working with you. Below are two things that I need you to sign before we proceed in treatment. The first is your HIPAA form, which goes over your rights as a patient, and the second is an agreement on fees and your acknowledgement that you will pay for this service. Please make sure that you fill out both forms. You will get email acknowledgements of each one separately.
NOTICE OF ACCEPTANCE OF HIPAA COMPLIANCE FORMS
Please take a look at the HIPAA form (click here to view the file) and keep a copy for your records. Then please fill out the form below acknowledging that you have received this form. If you have any questions about your HIPAA rights, please feel free to ask me.
ACCEPTANCE OF RESPONSIBILITY FOR PAYMENT OF SERVICES
I hereby affirm that I am the party responsible for payment of the fees charged by Joshua King, Psy.D. for psychotherapy, psychological testing, or diagnostic assessment within his private practice. I agree to the rate of $250 per 50 minute session (unless otherwise agreed upon with Dr. King).
I, not my insurance company, bear the ultimate responsibility for payment of incurred fees, even in the event that the insurance company fails to reimburse as anticipated. I understand that payment is required at the time each session occurs unless other arrangements have been agreed upon with Dr. King. I understand that I am expected to pay for scheduled sessions which I miss, unless I provide 24 hours notice of cancellation.
I also understand that I may not be able to seek reimbursement through my insurance
company for sessions which I miss.