Sign and return this form along a 25% deposit (except for Medicare and VR patients or those who are applying for a payment plan through Tuition Solutions) and you will be called to schedule an appointment. If you do not hear from Dr. Crum within a week, give us a call at 863-9657-2093. In the case of all manual testing, Dr. Crum and her assistant administer the tests. In the case of computerized administered tests, a coach will assist you if you are unfamiliar with computers.
We bill Medicare and Medicare supplemental insurers, as well as Vocational Rehabilitation. If you have other insurance, you will be provided a receipt appropriate for submission to your insurance carrier. If you want a specific insurance form submitted, please fill it out completely so that it only requires my signature. Additionally, you will need to provide me a copy of anything that I sign on your behalf. Specifically, I do not write extra reports for insurance companies, managed care companies, Social Security, schools or doctors without being compensated beyond the final report. Your signature below indicates agreement to these terms.
Standard Batteries at quoted prices assume the patient is on time and cooperative such that batteries can be completed in the normal range of time. If a patient requires additional time due to being late, lack of cooperation or the need for additional testing, the additional testing hours will be charged on a per hour basis. A $500.00 deposit is necessary to reserve the first appointment, and clients are expected to pay as they go. Complete payment is due at the final testing session.
As a psychologist, I am subject to strict standards for keeping records confidential. Therefore, if you want me to provide information to anyone, I can do so only with your written permission. Bear in mind, that once information is provided to another party, they may not be under the same obligations to keep your private information confidential. For instance, school districts share information with many employees, and insurance companies may share information among themselves.