Financial Agreement for Psychological Testing Services

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Here are the schedule of fees for psychological testing. However, the amount you will be responsible for will vary based on your individual situation and is dictated largely by your insurance plan, deductible amount, copay, coinsurance percentage, etc. The exact/quoted amount you will be responsible for will be explained to you before you schedule the appointment:
ADHD Testing: $750
Autism Testing (ages 3-5): $850 - also requires separate IQ testing ($300)
Autism Testing (ages 6-18): $1100 - also requires separate IQ testing ($300)
Autism Testing (ages 19-22): $850 - also requires separate IQ testing ($300)
Autism Testing (ages 23+): $750 - also requires separate IQ testing ($300)
Bariatric Surgery Consults: $600
Diagnostic Clarification: $800
Dyscalculia Testing: $850
Dyslexia Testing: $950
Learning Disability Testing: $600

IQ Testing: $300
Neuropsychological Testing: $900
Speech/Language Testing (ages 9-21): $750
Speech/Language Testing (ages 22+): $500
*Additional fees may be applied if specialized measures or further testing is recommended

Agreement:
I request that Providers for Healthy Living provide services to me and I agree to pay the fees in accordance with the fee schedule listed above. I understand that Providers for Healthy Living will obtain a quote from my insurance provider for the services requested, but that it is ultimately my responsibility to verify the quote given by calling my insurance provider. I understand that in the event my insurance provider does not cover partial or all services rendered, I will be responsible for the balance.

When you call your insurance company to verify benefits for psychological testing, use following CPT codes: 96130, 96131, 96132, 96133, 96136, and 96137.

Broken Appointments:
I understand that I will be charged $275 for any missed psychological testing appointment not cancelled 24 hours in advance.

Email *

Patient Name: *

Fee Schedule *

I acknowledge that I have reviewed the fee schedule for psychological testing services and have asked questions, if necessary.

Required

I request that Providers for Healthy Living provide services to me and I agree to pay the fees in accordance with the fee schedule listed above. I understand that Providers for Healthy Living will obtain a quote from my insurance provider for the services requested, but that it is my responsibility to verify the quote given by calling my insurance provider. I understand that in the event my insurance provider does not cover partial or all services rendered, I will be responsible for the balance as per insurance companies "A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member's contract at the time of service." *

I acknowledge that it is my responsibility to verify insurance benefits for psychological testing services and accept financial responsibility for all services provided to me or my child/dependent.

I understand that I will be charged $275 for any missed psychological testing appointment not cancelled 24 hours in advance. *

I acknowledge that I have been informed of the fee for missed psychological testing appointments.

By typing your name below, you are signing this agreement electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this agreement. PLEASE TYPE THE NAME OF THE PERSON ACCEPTING FINANCIAL RESPONSIBILITY (PATIENT OR OTHER ADULT, IF THE PATIENT IS A MINOR). *

Send me a copy of my responses.

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