MAVIS M. ALAIMALO, PSYD, CSAC, LTD
98-084 Kamehameha Highway, Suite #301B Aiea, HI 96701
Tel: (808) 486-4900 – Fax: (808) 486-4901
PATIENT CONSENT TO TREATMENT & CONTRACT
Welcome to my practice! This document contains important information about my professional services and business policies. We are also committed to providing you with the best possible care. If you have medical insurance, we are happy to assist you in receiving your maximum allowable benefits. In order to achieve these goals, we need your help, and understanding of our payment policy. Please read it carefully. When you sign this document, it will represent an agreement between us.
I. PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.
II. MISSED APPOINTMENTS
We respectfully require a 24-hours notice in the event you cannot keep your appointment. A flat fee of $85.00 will be assessed and, DUE at your next scheduled session. Our answering machine is available during off hours to take any messages. To help better serve you, please keep your scheduled appointment.
III. PAYMENTS & INSURANCE REIMBURSEMENT
If you have insurance coverage, please understand that this is a contract between you and your insurance company. As a courtesy to you, we will assist by submitting claims for reimbursement provided that we have all the necessary information. We will also gladly discuss your proposed treatment and answer any questions relating to your insurance. Please know that your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. If you do not have health insurance, please know that you will be responsible for payment of session at the time of service.
IV. PROFESSIONAL RECORDS
I am required to keep records of the professional services I provide of our work together. Because these records contain information that can be misunderstood by someone who is not a mental health professional, a brief treatment summary, may be provided upon request only. A request in writing is required for release of records, and may take up to two weeks to process. Please note that this is a professional service and as such may be subjected to a fee at my discretion.
Your signature below indicates that you have read the information in this document and you understand and agree to abide by its terms.