CUMMING, GA  OFFICE
6030 Bethelview Rd. #401
CUMMING, GA 30040
(770) 205–5760 Off
(770) 205–5780 fax


LICENSED CLINICAL PSYCHOLOGIST

GEORGIA License. # 896, since 1984     

  
Intake Forms


The following pages are intended for use by our clients (new & existing) only. They are copyrighted and must not be used for any other purpose than that associated with visits for treatment with Dr. Feinsilber.

Fee Schedule as of January 1, 2005

Service Description Session
Initial Intake $150.00
Family or Couples Sessions $150.00
Individual Sessions $125.00

(Note: sessions are based on a 45-minute hour)
 

Payment: the client will be expected to pay for each session at the time services are rendered. If the client belongs to an HMO/PPO/POS entity with which APS is affiliated, the client may be required to make a co-payment at each visit, the amount of which is determined by the client’s contract with his/her insurance company. This co-payment can be predetermined for the client upon the client’s furnishing APS’ Office Manager with relevant information (ID card, authorization # etc.).

As a courtesy, APS will file for insurance reimbursement as well as verify client’s benefit payment. However, the client will be ultimately responsible for the payment of any professional fees, regardless of the client’s insurance coverage at the time of service, in the event that either the client’s insurance company or any other client’s provider organization, allied with the client’s carrier, denies APS’ claim or is delinquent with reimbursements to APS. (As part of APS’ verification process with all insurance companies APS is provided up front with a disclaimer by the insurance companies, stating that the information provided “is not a guarantee of payment”).

It is official APS Office Policy that the client will be billed whenever the client’s existing account exceeds a running balance of $100.00 at which time the client will be asked to bring his/her account current. In the event that APS subsequently receives surplus insurance reimbursements, these will then be refunded promptly to the client.

Checks, which are written to us by clients, which are returned by the client’s bank for any reason, will require the client to pay APS immediately for that amount, either in cash, money order or cashier’s check. A returned check surcharge of $50 will be added to this amount and is payable in full.

Pre-scheduled telephone sessions or other impromptu calls that exceed five minutes are charged at the rate of $125.00 per hour (time prorated in fractions of that hour). Please be aware that this includes also times the client may choose to page Dr. Feinsilber with a clinical emergency,

Services provided outside the APS facilities (Norcross or Cumming), i.e. court appearances, agency or school consults etc., are billed at a rate of $150.00 per hour, plus travel time (2 hours minimum).

If psychological testing is performed, there are individual charges for each test administered, which the client is responsible for. These charges are to be paid in full at the time of administration of testing. Testing fees include full VERBAL feedback. However, if the client requires a formal WRITTEN report, this report will be billed separately and is usually not covered by the client’s insurance company. Please be advised that no testing results or interpretations of any tests will be provided to the client, until all testing fees have been paid in full, including report charges, is a report is to be handed over to the client in writing. Testing benefits through the client’s insurance company, if any exist, can be predetermined for the client by our Office Manager prior to these services being rendered. In these cases, the client’s fee responsibilities may be diminished.

Cancellations/Unkept Appointments/Lateness: Unkept appointments or appointments, which are not cancelled at least 24 hours prior to the appointment time, will be charged for. APS has a 24-hours, 7-days-a-week voice mail coverage as well as pager coverage for emergency calls and cancellations. Unforeseen legitimate emergencies (sudden serious illness, accidents, family deaths,) which occur less than 24 hours prior to the appointment time, which require the client to cancel his/her appointment, are usually negotiable in terms of fees incurred.

Managed Care, you – the client – and your treatment

I, Dr. Feinsilber, have agreed to see you, the client, under the terms set by the Managed Care Company, which oversees your (the client’s) mental health benefits. In order to avoid misunderstandings regarding what this means, I am outlining some of the general aspects of Managed Care below.

Managed Care means that an outside company has been engaged to select approved therapists and to determine both your need for treatment and the length of time that treatment will be provided for. If I am working with you (the client) as a managed care patient, I have entered into a contract with the Managed Care Company. While the contracts may vary somewhat, you (the client) should be aware of the following, which applies to ALL cases:

The Managed Care Company will receive regular and somewhat detailed reports regarding your (the client’s) symptoms, diagnosis and treatment. There are no restrictions on the type or amount of information that the Managed Care Company may require from me. I will be glad to discuss the content of these reports with you, the client. While my experience is that the information provided has been treated with an appropriate degree of confidentiality, I cannot be responsible in any way for the Managed Care Company’s use or disclosure of the information provided to them.

In many instances, the Managed Care Company must approve all sessions in advance. Each Managed Care Company has its own criteria regarding what it will consider as a ‘medical necessity’ for therapy. Therapy sessions beyond what is determined medically necessary by the Managed Care Company must be paid for by you, the client, directly, should you, the client, and I agree to continue to meet after the number of authorized sessions has expired.

 

©2005 AFFILIATED PSYCHOLOGICAL SERVICES, P.C.  All rights reserved.