Patient Health Questionnaire-9 (Phq-9) Template/form Gad-7 (Page 5 of 8) in pdf

Neal Brugman, Psy.D.

(720) 295-7605

If a report, letter or consultation with an outside party is requested, you will be billed for

any time needed to prepare documentation, or to conduct and in-person or phone

consultation.

Forms of Payment & Policies:

The Collaborative Center accepts the following forms of payment: Visa, MasterCard,

Discover, Health Savings debit cards, cash and personal checks. Clients will be responsible

for payment at the time services are rendered.

Cancellation Policy:

In the event you need to cancel an appointment, please notify me at least one (1) business

day in advance. If less notice is given (“late cancelation”), or no notice is given (“no show”)

you will be charged the full session fee.

Inclement Weather Policy Cancellation Policy:

If Denver Public Schools cancels classes due to weather, Dr. Brugman will waive late

cancellation fees for that day. In these instances, Dr. Brugman will assume you are

attending unless he receives notice from you before your session - clients who do not give

notice of missing an appointment (“no show”) will still be charged the full session fee

regardless of weather conditions.

Please initial here indicating that you have read and understand the cancellation

policy: ____

Insurance:

Dr. Brugman only bills directly to the following insurance companies: Rocky Mountain

Health Plans, Multiplan, Mines and Associates, and Medicare. If you would like to utilize

your insurance benefits for any other plan not listed above, you will pay me directly and

then be provided with insurance-ready statements which you will then submit to your

insurance carrier.

Policy for Non-Payment:

In the event billing efforts fail, delinquent accounts may be subject to collections. This

practice will make every attempt to develop a payment plan with any client struggling to

pay a past due balance prior to sending a balance to collections.

Additional Information

Dr. Brugman routinely consults with other professionals in the field regarding ongoing

therapy and assessment cases. Privacy and Confidentiality are always maintained in these

consultations.

Required Signatures

I understand and agree to the preceding Disclosure Statement, Consent for Treatment,

Financial Agreement and the Addition Information provided above.

________________________________________________

_________________

Signature of Client or Legal Guardian

Date

The Collaborative Center, LLC

Patient Health Questionnaire-9 (Phq-9) Template/form Gad-7 Page 5