Healthcare Evaluation Services

Healthcare Evaluation Services

Patient Information

Patient Name:

Date of Birth:   Gender:

Referral & Evaluation Details

Referred By:

Neuropsychological evaluation
Psychological assessment
Physical therapy evaluation
Occupational therapy evaluation
Speech-language evaluation

Insurance & Billing

I understand that I am financially responsible for charges not covered by insurance, including missed appointment fees and portions of the evaluation not authorized by my insurer.

Medical History

Primary Care Provider:

Consent for Evaluation

I, the undersigned, authorize and consent to the performance of the evaluation services selected above. I understand that the evaluation may include interviews, standardized testing, clinical observation, review of records, and other assessment techniques as appropriate to the referral question. The provider will explain the nature, expected benefits, possible risks, and alternatives prior to or during the evaluation.

I understand that there are limits to confidentiality, including but not limited to obligations to report suspected abuse or neglect, court orders, and reasonable belief of imminent risk of harm to self or others. I understand that test results and clinical impressions will be documented in a report and in my clinical record.

I authorize the evaluator to obtain relevant records and to communicate findings with the referring provider, insurance carrier as required for reimbursement, and other identified providers for continuity of care. This authorization is effective for the duration specified below and may be revoked in writing except to the extent that action has already been taken in reliance upon it.

I understand I may withdraw consent at any time by providing written notice; however, withdrawal will not affect uses and disclosures already made in reliance on this authorization prior to receipt of the revocation. I understand that refusing or withdrawing consent may affect the ability to complete the requested evaluation and may impact coordination of care.

Privacy Acknowledgment (HIPAA)

I acknowledge that I have been offered a copy of the Provider's Notice of Privacy Practices describing how my health information may be used and disclosed, and my rights regarding that information. I authorize the use and disclosure of my protected health information as described in this document for treatment, payment, and healthcare operations as necessary for the evaluation.

I consent to the release of evaluation reports and clinical summaries to the following persons or organizations (include names and relationships):

Administrative Terms

Cancellation & No-Show Policy: Appointments not cancelled within the provider's required notice period may be subject to a fee. I agree to notify the office as soon as possible if I cannot attend a scheduled appointment.

Ownership of Records: Clinical records and evaluation reports are the property of the provider. Copies of records or reports may be provided to the patient or disclosed to authorized parties in accordance with applicable law and agency policy.

Interpreter / Accessibility Needs

Interpreter required:    Hearing or visual impairment requires accommodation:

Patient Certification

I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand the nature of the requested evaluation, the limits of confidentiality, and my financial obligations as outlined above. By signing below I give informed consent for the evaluation and for the release of information as specified.

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