I have received this practice's Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights and the practice's legal duties with respect to my protected health information. The Notice includes:

• A statement that this practice is required by law to maintain the privacy of protected health information.
• A statement that this practice is required to abide by the terms of the notice currently in effect.
• Types of uses and disclosures that this practice is permitted to make for each of the following purposes: treatment, payment, and health care operations.
• A description of each of the other purposes for which this practice is permitted or required to use or disclose protected health information without my written consent or authorization.
• A description of uses and disclosures that are materially limited by law.
• A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization.
• My individual rights with respect to protected health information and a brief description of how I may exercise these rights in relation to:
• The right to complain to the Privacy Officer of this Practice and to the Secretary of HHS if I believe my privacy rights have been violated, and that no retaliatory actions will be used against me in the event of such a complaint.
• The right to request restrictions on certain uses and disclosures of my protected health information, and that this practice is not required to agree to a requested restriction.
• The right to receive confidential communications of protected health information.
• The right to amend protected health information.
• The right to receive an accounting of disclosures of protected health information.
• The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request.

This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice's current Notice of Privacy Practices on request.

Child & Family Psychologist/Independent Contractors

INITIAL CONSENT FOR TREATMENT

FINANCIAL AGREEMENT/ POLICIES AND PROCEDURES

(Please read and return both pages of this form)

Payment is expected at the time of service, unless other arrangements have been made in writing. I understand and agree that I am responsible for the full bill, and that reimbursement is not a substitute for payment. It is my responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by my insurance company. I understand and agree that a finance charge of 1.5% per month will be added to accounts which have an overdue balance beyond thirty (30) days. I am aware and agree that should my account become delinquent beyond ninety (90) days an attorney and/or collection agency will utilized to obtain payment in full, and that I will be charged a reasonable fee for the cost of collection. I understand and agree that confidentiality is not being broken if the collection agency chooses to make public the information that Child & Family Psychologist who is functioning as the billing agent for the Clinical Associate/Independent Contractor providing the Psychological Services. To avoid such procedure I agree to keep my account current. I also agree to pay a $30.00 for returned checks(s).

I hereby assign alt insurance major medical benefits, which may include private insurance and/or other health plans to: Child & Family Psychologists who is functioning as the billing agent for the Clinical Associate/independent Contractor providing the Psychological Services. I hereby authorize the stated assignee to release all information necessary to secure payment. I understand and agree that all phone calls made to verify insurance coverage may be charged to my account. I understand and agree that a charge equal to the full fee will be made for all appointments which are canceled with less than 24 hours notice, and for scheduled appointments that I miss without providing notification. I understand that my insurance company is not responsible for any payment towards canceled appointments. However, emergency cancellations will be considered on an individual basis.

At time, adults other than parents or guardians may transport children or adolescents to their sessions. Some teenagers attend sessions without their parents present. All of us have left home without our checkbooks. We often believe that our insurance will pay one amount, when in actuality they pay a lesser percentage toward service rendered. In each of these cases, should one occur, I give my permission for Child & Family Psychologists as the billing agent for my Therapist/Independent Contractor to charge my Visa, MasterCard, American Express, or Discover for the appropriate remaining balance of any unmet deductible on my insurance, any co-payment not made at the time of Psychological Services, or any canceled or missed appointments with less the 24 hour notification provided.

The clinical Associate/Independent Contractors working at Child & Family Psychologists will make every effort possible to rapidly return phone calls. However, should an emergency exist after normal working hours. I will contact either University Pavilion Hospital, Memorial Regional Hospital, CPC. Fort Lauderdale Hospital, or any other Psychiatric facility of my choice if I am considered to be a danger to myself or to others. Otherwise, I will place a second call to the answering services, and schedule an emergency appointment with my Therapist/Independent Contractor as soon as possible. I authorize and request for my Therapist to carry out Psychological Evaluation, Treatment, and/or Diagnostic Procedures for either myself or my child which are considered to be necessary by my Therapist. I agree to attend sessions knowing there is no guaranteed outcome. However, I am aware that all therapeutic interventions will theoretically based. If I am dissatisfied with services. I will terminate therapy and accept an appropriate referral. I am aware that my Therapist/Independent Contractor will do his or her best to help me obtain my therapeutic goals. I understand that in situations of suspected physical, emotional, and/or sexual abuse that my Therapist is obligated by law to file an oral and written report to The Department of Children and Families requesting an emergency investigation. The limits of confidentiality relate to situations of danger to self or others. Treatment Summary Letters may be provided by my Therapist with a properly signed Client Information Release Authorization in lieu of releasing the complete psychological records to either myself or any other requesting party. If I attend Group Psychotherapy, I will maintain confidentiality with respect to information disclosed by other patients. I understand that a violation of this confidentiality could potentially result in legal action against me personally. This agreement in its entirety will remain in effect until revoked by me, in writing.

The standard out-patient fees of Clinical Associates/Independent Contractors practicing at Child & Family Psychologists are: $195.00 for a Diagnostic Interview, and $180.00 for each 45 minutes of Psychological Service. In-patient Psychological Services are provided at a rate of $195.00 per 45 minutes, and Psychological Evaluations are conducted at a rate of $300.00 per hour. However, the Independent Contractors are under contract with many insurance companies and are bound to utilize their fee structures. Unless otherwise indicated, the standard fees shall be utilized.

1. If you are unable to attend your scheduled appointment, we require that you call us to cancel your session with a minimum of 24 hours notice. Otherwise, you will be charged $50.
2. If you do not attend your scheduled appointment, and do not call to cancel, you will be charged our full and customary fee. (Insurance can not be charged for missed/cancelled appointments).

Please understand that if time is designated for you from our schedules, this precludes our ability to schedule other patients in the office at that time. However, we do understand that extenuating circumstances may arise over which you have no control, and for these isolated situations, no fee will be charged. In any event, please call our office as soon as you know that you will not be able to attend your scheduled session. Thank you for your cooperation.

I have read, understand, and agree with the entire contents of this form:

"Because of HIPAA guidelines, we are asking our patients to only sign, date, and fill out their name. For your security, to provide your credit card information please give our office a call at 954-587-7520 or 954-379-2777."

The office of Child & Family Psychologists and its independent Contractors request that a copy of your Credit Card number be placed into your confidential secure file.

Your Credit Card will only be used for the following Reasons:

• Unpaid co-payments
• Unpaid no-show and/or late cancellation fees
• Returned Check Fees
• Any and all insurance monies that are not paid by your insurance company including: deductibles not paid, health funds that expire or have a lack of funds for payment, cancelled or expired policies, funds due as a result of lapses due to changes in insurance policies, or benefits denied by your insurance company

I give my permission for Child & Family Psychologists as the billing agent for my Psychologist/Therapist/Independent Contractor to charge my Visa, Master Card, American Express, or Discover Card for the above listed reasons.