Mario J. Frabizzio Jr., Ph.D.LICENSED PSYCHOLOGISTCONCORD PLAZA202 Webster BLDG. OFFICE: (302)-479-5151
3411 Silverside Rd. FAX: (302)-654-9720
(302)-654-9720Wilmington, DE 19810 email: marfrajr@comcast.net
Website: http://www.mariofrabizziophd.com
NEW PATIENT INFORMATION FORM
Hello and welcome to the office of Dr. Mario J. Frabizzio, Jr. Please take the time to read this information thoroughly and allow me to familiarize each of you with the policies of this practice. The main goal of treatment is the patient’s well-being and emotional health; treatment approaches and plans are discussed from this perspective.
This packet contains all of the policies of this practice and required forms necessary to be treated through your Insurance provider and your plan. If you have any questions regarding this information, I will be happy to review the completed paperwork with you.
All patients should review and sign the:
1. STANDARD OFFICE POLICY; 2. FINANCIAL POLICY STATEMENT; 3. ASSIGNMENT OF INSURANCE BENEFITS
NOTICE OF PROVIDER’S POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION
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STANDARD OFFICE POLICY
1.Above all else, CONFIDENTIALITY is respected and therefore will be addressed during the first visit. This is a HIPAA compliant practice (See HIPAA section).
Above all else, CONFIDENTIALITY is respected and therefore will be addressed during the first visit. This is a HIPAA compliant practice (See HIPAA section).2.All first visits are “Initial Evaluations” and will be 45 minutes in duration. During this initial session, the presenting problem(s) will be explored, background information will be gathered and insurance, financial, and billing information will be discussed.
All first visits are “Initial Evaluations” and will be 45 minutes in duration. During this initial session, the presenting problem(s) will be explored, background information will be gathered and insurance, financial, and billing information will be discussed.3.All subsequent therapy visits will be 45 minutes in duration. This time includes the scheduling of appointments as well as payment collection for the current session. In order to optimize the session time, payment (CASH or CHECK ONLY) should be prepared in advance to facilitate this transaction. If possible, two appointment sessions will be scheduled at each visit to ensure that the next appointment has already been set and confirmed.
All subsequent therapy visits will be 45 minutes in duration. This time includes the scheduling of appointments as well as payment collection for the current session. In order to optimize the session time, payment (CASH or CHECK ONLY) should be prepared in advance to facilitate this transaction. If possible, two appointment sessions will be scheduled at each visit to ensure that the next appointment has already been set and confirmed. 4.Late Arrival Policy: Since appointments are tightly scheduled you are urged to allow enough time to negotiate transportation in order to arrive promptly for your session. If you are late, no additional time can be given and you are limited to the remaining time from your scheduled visit. If I am late you will be given your full session time. With rare exception, I run on time or only a few minutes behind.
Late Arrival Policy: Since appointments are tightly scheduled you are urged to allow enough time to negotiate transportation in order to arrive promptly for your session. If you are late, no additional time can be given and you are limited to the remaining time from your scheduled visit. If I am late you will be given your full session time. With rare exception, I run on time or only a few minutes behind. 5.Cancellation Policy: Due to limited available appointment times, advance notice of scheduling conflicts is appreciated. 24-hour cancellation notice is required. Cancelled appointments are not billed. All other unattended visits are considered BROKEN and are billed at a flat $75 fee. Please note that no insurance company covers any percentage of BROKEN appointment fees.
Cancellation Policy: Due to limited available appointment times, advance notice of scheduling conflicts is appreciated. 24-hour cancellation notice is required. Cancelled appointments are not billed. All other unattended visits are considered BROKEN and are billed at a flat $75 fee. Please note that no insurance company covers any percentage of BROKEN appointment fees.6.Payment Policy: Payment is expected upon delivery of service. The exact payment schedule will be discussed at the initial visit. Payments can be made by check or in cash. Credit/Debit cards are currently NOT accepted. Bounced-check banking fees are the responsibility of the patient plus a $40 charge is due to this office.
Payment Policy: Payment is expected upon delivery of service. The exact payment schedule will be discussed at the initial visit. Payments can be made by check or in cash. Credit/Debit cards are currently NOT accepted. Bounced-check banking fees are the responsibility of the patient plus a $40 charge is due to this office. 7.Insurance Plan Policy: Most managed-care services are not covered in this practice. “Out-of-network” insurance plans can have a yearly deductible typically on a “calendar year” cycle. Deductibles can range from $500 to $5000 and are the responsibility of the patient. All session fees are applied to the deductible and, since reimbursement is withheld until the deductible is met in its entirety, it is essential that all fees be paid in full as services are rendered until one's deductible is met.
Insurance Plan Policy: Most managed-care services are not covered in this practice. “Out-of-network” insurance plans can have a yearly deductible typically on a “calendar year” cycle. Deductibles can range from $500 to $5000 and are the responsibility of the patient. All session fees are applied to the deductible and, since reimbursement is withheld until the deductible is met in its entirety, it is essential that all fees be paid in full as services are rendered until one's deductible is met. This practice currently accepts “in-network” insurance coverage from Aetna, Blue Cross/Blue Shield of DE and Cigna. Co-Pays vary by specific plans so if you plan to use your “In-Network” or “Out of-Network” insurance benefits for your treatment we request that you verify your benefits by calling your company and obtaining any necessary authorizations prior to scheduling your first appointment and having proper information regarding the correct Co-Pay fee specific to your benefits for “Mental Health Outpatient Services”. Frequently used one unit session CPT Codes are:
90791 Initial Evaluation; 90834 Individual Session; 90847 Family Session.
Please note, that as covered in the Financial Policies Summary, you will be billed separately and held responsible for any portion of the treatment that you receive and your third party payment does not cover, regardless of the reason for denial. If you have a co-pay, coinsurance, or deductible with your insurance company, please know what it is and be prepared to pay this amount at the time of your appointment. If you are taking independent financial responsibility for your services please come prepared to pay your testing/treatment fees in full. Non-Insurance Services: Same as Insurance fee; no reduced fees apply.
8.Phone Policy: Any need for a patient to call me is welcomed, however, it is unlikely that you will reach me in person. Voice mail messages provide information regarding the most appropriate access until I am able to return calls and detailed messages when calling are helpful. Routine phone contacts with patients limited to 10 minutes or less are not billed, however, if phone discussions with patients require more time, they are considered “phone therapy” and will be billed accordingly as a teletherapy session.
Phone Policy: Any need for a patient to call me is welcomed, however, it is unlikely that you will reach me in person. Voice mail messages provide information regarding the most appropriate access until I am able to return calls and detailed messages when calling are helpful. Routine phone contacts with patients limited to 10 minutes or less are not billed, however, if phone discussions with patients require more time, they are considered “phone therapy” and will be billed accordingly as a teletherapy session.9.Email Policy: Patients are encouraged to use email for NEW REFERRALS and ancillary contact.
Email Policy: Patients are encouraged to use email for NEW REFERRALS and ancillary contact.10. Deposits: Psychological/Psycho-educational testing typically requires two 3 hour sessions. Sessions are generally in the morning and are scheduled a week apart. Testing services may be subject to a $250 deposit paid in advance in order to guarantee the 6 hour time slot required for testing. This cost will be applied to the fee.
11. Miscellaneous Policy: Any consultation between professionals is billable if more than 10 minutes in length. The exception is brief email contact (no charge). Report writing or forwarded reports will also be billed according to the rate schedule below.
If you have any questions prior to your appointment, please either email me at marfrajr@comcast.net or call the office at (302) 479-5151. If you must cancel your appointment, please notify me at least 24 business hours (72 for testing) prior to the scheduled appointment time. Failure to provide adequate notice will result in a missed appointment charge per our fee schedule, which is not typically a benefit of most insurance policies.I look forward to working with you and your family.
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FINANCIAL POLICY STATEMENT
The following is a summary of our financial policy. Details are provided in the Provider-Patient Services Agreement. We ask that you review and sign both documents before beginning treatment. Your signature indicates that you understand and agree to follow our financial policy. As all patients must agree and are held responsible for all policies if you have a question or concern please discuss this with the practice director
(Mario J. Frabizzio Jr., Ph.D.) prior to engaging in treatment.
Insurance Coverage:
Your health insurance is a contract between you and your insurance carrier. It is your responsibility to know the terms contained in your policy regarding coverage, co pays, coinsurance, deductibles, and non-covered services. If you have any questions about your insurance, you will need to contact your carrier directly. Current insurance cards must be presented at the initial appointment and/or when coverage changes. You are responsible for all costs not covered by your insurance carrier regardless of the reason for denial.
Your Initials here:
Missed Appointments:
Cancelled appointments require 24 business hour notice. Without 24 business hours notice, you will be charged as follows:
• All Non-Insurance or “Out-of-Network Appointments: Full Fee ($125)
• All “In-Network” Appointments: $75 per appointment hour
• Psychological Testing: Billed your $250 deposit in addition to normal test fees.
Your Initials Here:
Co-pays, Self-Pays, & Outstanding Balances:
ALL co pays, coinsurance, and deductible amounts are due at the time of service. If your account has as
outstanding balance, you will be expected to pay before seeing the provider or at the latest pay for the outstanding session plus that day’s session at the start of the following session. I accept cash and personal checks ONLY at this time. All unpaid balances outstanding for more than 60 days may be forwarded to a collections agency with all fees associated with collections being added to our account. Current collections fees are 35% of your balance. All self-pay office visits must be paid at the time of the visit or may incur the same charges as outstanding balances.
Your Initials Here:
Miscellaneous Fees:
If your provider is required to complete forms on your behalf, all attempts should be made to do this as part of your scheduled appointment. If this is not possible or you prefer that they be completed outside of your scheduled time, a charge will be incurred and will not be covered by your insurance company. The charge for completing forms including but not limited to leave of absence, FMLA, and Short/Long Term Disability, medical, and legal letters is a minimum of $50 or a prorated amount of the provider’s normal hourly fee. I require that you have been seen three times prior to completing any disability forms. All forms will normally be completed within 10 days.
Other Fees:
• Returned checks: $40 service fee per returned item.
• Receipts or Statement fees are provided at no charge and are emailed to patients in a timely fashion.
All requests for additional statements may incur a $5 charge
• Medical Records: requests by you or anyone other than your medical insurance company for your records may incur a minimum $50 per patient plus $1.00 per page charge.
• Collections: any accounts with a balance that have not been paid for 60 days from the date of service may be forwarded to collections without additional notice. Collection costs will be added to your balance. Current rates are 35% of the balance.
Your Initials Here:
My signature indicates that I have read this policy, and that I understand and agree to Mario J. Frabizzio’s Financial Policy*.
Patient name: ._______________________________________________________
Patient/Guardian Signature: Date:.________________________________________
*If you have any questions regarding these financial policies please call:
Mario J. Frabizzio Jr., Ph.D. (Practice Director) at 302-479-5151.
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ASSIGNMENT OF INSURANCE BENEFITS
I hereby authorize and request my insurance company pay directly to this psychologist, Mario J. Frabizzio Jr., Ph.D. the amount(s) shown on my claims for services rendered to me or my dependent. I further agree that should the amount be insufficient to cover the entire medical expense, I will be responsible for payment of the difference, and if the nature of the disability be such that it is not covered by the policy or exceeds my benefits, I will be responsible to Mario J. Frabizzio Jr., Ph.D. for payment of the entire bill.
I CERTIFY THAT THE ABOVE IS CORRECT
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______________PATIENT’S/GUARDIAN’S SIGNATUREDATE
DATE_____________________________________________________________
________________INSURED’S SIGNATURE DATE
DATENOTICE OF PROVIDER’S POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION
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This notice describes how psychological and medical information about you may be used
and disclosed and how you can get access to this information. Please review it carefully.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To clarify terms, here are definitions:
• “PHI” refers to information in your health record that could identify you.
• “Treatment, Payment, and Health Care Operations”
* Treatment is when I provide, coordinate, or manage your health care and/or other services related to your health care or consult with another health care provider.
* Payment is when I obtain reimbursement for your health care. Payment includes when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
* Health Care Operations are activities that relate to my private practice’s performance and operation. Examples of health care operations are quality assessment, business-related matters such as audits and administrative services, and case management and care coordination
• “Use” applies only to activities within my office, such as sharing, employing, applying, utilizing. examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your treatment authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances, when you are asked for information for purposes outside of treatment, payment, and health care operations, I will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes your clinician has made about your conversation during an interview or a private, group, joint, or family counseling session, which they have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that I have relied on that authorization, or if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under policy.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
• Child Abuse: If I have reasonable cause, on the basis of my professional judgment, to suspect abuse of children with whom I come into contact in my professional capacity, I am required by law to report this to the Department of Child Welfare.
• Adult and Domestic Abuse: If I have reasonable cause to believe that an older adult is in need of protective service (regarding abuse. neglect, exploitation, or abandonment), I may report such to the local agency which
provides protective services.
• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services I provided you or the records thereof, such information is privileged under state law, and I will not release the information without your written consent, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. In this case you will be notified.
• Serious Threat to Health or Safety: If you express a serious threat, or intent to kill or seriously injure yourself or an identified or readily identifiable person or group of people, and I determine that you are likely to carry out that threat, I must take reasonable measures to prevent harm. Reasonable measures include notifying minor's parents, directly advising the potential victim of the threat or intent, or notifying the police.
• Worker’s Compensation: If you file worker’s compensation, I am required to file periodic reports with your employer which include, pertinent history, diagnosis, treatment, and prognosis.
IV. Patient’s Rights and Provider’s Duties Patient’s Rights
Patient’s Rights
• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of PHI about you, however, I am not required to agree to the restrictions you request.
• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example. you may not want a family member to know that you are in therapy with me. Upon your request I will send your bills to another address).
• Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in our mental health billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.
• Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, we will discuss with you the details of the amendment process.
• Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). Upon your request, I will discuss with you the details of the accounting process.
• Right to a Paper Copy: You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
Provider’s Duties
• I am required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
• I reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, I am required to abide by the terms currently in effect.
• If I revise policies and procedures, I will notify you by mail with a revised notice.
V. Complaints
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about your access to your records, we can discuss this or you can call me, Mario J. Frabizzio Jr., Ph.D. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.
VI. Effective Date, Restrictions and Changes to Privacy Policy
This notice went into effect April 30, 2003. I reserve the right change these terms
My signature on this form confirms that I have thoroughly read, understand, and agree to the PROVIDER’S POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION.
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Print Patient’s Name
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Patient’s Signature
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Parent or Guardian (if applicable)
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Date
