1800 Town Center Drive, Suite 411
Reston Virginia 20190
703-437-3236
STATEMENT OF POLICY
providing the highest quality of psychotherapeutic and psychodiagnostic
services, offering individual,
family, and group therapies. Reston
Psychological Center (RPC) provides diagnosis and treatment
of behavioral, emotional, academic, and social difficulties in children, adolescents,
adults, and families.
APPOINTMENTS: Office hours are available
by appointment from
is open Monday through Friday from
during these hours. Routine telephone inquiries, billing and scheduling,
can be addressed during the
business day.
are provided to the highest possible standards.
EMERGENCY SERVICE: Emergency
telephone consultation services are available on a 24 hour basis
for patients of RPC. During office
hours, please inform the receptionist of the situation. After hours and
weekends, a voice mail service is available.
Each therapist remains on call for his or her own clients, but
backup coverage is provided by other staff members.
Please call the office number and follow the voice
mail instructions for an emergency and the therapist on call should reach
you as soon as possible.
In case of life threatening emergencies, first contact an ambulance service
or police department to
arrange transfer for you to a hospital emergency room or mental health center,
then call our office.
FEES: Fees vary with the type
of professional services provided and are explained upon the first
contact in scheduling an appointment. Charges
may be made for telephone contact time, additional
consultations, court time and school contacts.
Changes or cancellations of appointments must
be at least two business days in advance.
As your appointment time is reserved especially for
you, a charge will be made for missed or late canceled appointments. Please
be informed that
insurance carriers do not cover charges for missed or late cancellation appointments.
BILLING STATEMENTS:You will receive a billing statement at the time service
is rendered.
This statement can be used for filing insurance claims and/or should
be kept for your records.
PAYMENT: Payment is to be made at the time services are rendered. Co-payments or
co-insurance payments are made at the time of the visits.
You as the patient, are responsible
to read and understand your insurance plan and benefits.
We advise you to verify your mental
health benefits and co-payments. We
will file claims only for patients who see an in-network
participating provider. Regardless of an insurance or managed care company’s
response
regarding a service or charge, the patient/financially responsible party is
responsible for
charges incurred.
In the event
the financially responsible party fails to pay for treatment and the account
is given
to an attorney for collection, the responsible party also agrees to pay all
costs of collection, including
interest, court costs and attorney’s fees.
Your signature
below indicates that you have read the information in this document and agree
to abide by its terms during our professional relationship.
_______________________________________ _______________________
Signature
of Patient/Guardian Date