Amanda S. Kleinman M.D.
TREATMENT AGREEMENT
Confidentiality
All information shared in the patient-provider setting will be kept private and confidential in accordance
with the law and professional ethics. No information will be released to family or friends, insurance
providers, schools, employers, lawyers, etc. without patients’ written consent. If patients would like me to
share information about the condition or treatment, they will be asked to sign an agreement giving me
permission to do so.
Please know, however, that the law does require me to share specific confidential information without
patients’ written consent in the following circumstances:
(a) when there is the risk of potential harm to the patient’s self or to others
(b) when a judge issues a court order for the information (e.g. child custody cases)
(c) when there is an instance of suspected abuse of a child or elderly adult
Additionally, there may come a point in treatment where I may need to consult other providers for how to
help my patients best over the course of treatment. In such instances, I will carefully limit the conversation
with my colleague so as to not reveal the identity of or any suggestive details about the patient.
Appointment Time, Cancellations and Missed Appointments
As an important sign of respect to all of my patients, I expect to start and end visits on time. I will be in
the waiting room a few minutes before the start time in order to bring patients back to my office. I
strongly encourage patients to arrive 5-10min prior to the start of their appointment so that the
appointment can begin on time. Patients who arrive late will be charged for the full appointment time
they were allotted and the appointment will still end at the regularly scheduled time. I will give a 5-minute
warning at the end of appointments in order to allow time to wrap up the session. Information that a
patient has not shared prior to that point in time may have to wait until the next appointment.
Patients may cancel their appointment without charge up until 6:00 PM of the day before the
appointment. Any appointments cancelled after 6:00 PM the day before the appointment, and any
appointments missed without a call to cancel, will be charged the full fee of the last scheduled
appointment. Fees for missed visits are NOT covered by insurance.
I may waive the cancellation charge for extreme circumstances, including medical or psychiatric
hospitalization. However, I cannot waive the cancellation charge for reasons such as: forgetting the
appointment time or date, problems with transportation, problems with child care, problems with work
coverage, or viral illnesses like the cold or flu. Patients may opt for a Telephone Session instead of a late
cancellation. Fees for Telephone sessions are listed below.
Patients should receive a courtesy email reminder about their next upcoming visit. Occasionally the
system does not send reminder emails. Regardless of whether patients receive the reminder email or not,
patients are still responsible for attending or cancelling their appointments in a timely fashion.
January 2016
Amanda S. Kleinman M.D.
Fees
Fees for clinical services are as listed below and may be reassessed and adjusted each January. [Patients
using Blue Cross/Blue Shield will be charged fees according to the fee structure laid out by the insurance
company. By being in network, I have agreed to accept their fees.]
New Evaluation (120min) with or without prescription of medication: $350
Psychotherapy (55min) with or without medication management: $250 – 300
-
Discount available for patients receiving weekly therapy and not using insurance (cash only)
Medication Management (25min) with or without brief psychotherapy: $150 - $200, depending on level of
complication.
Fees for ancillary services, NOT covered by insurance:
Paperwork fees:
Completion of letters, disability forms or other ancillary paperwork outside of a visit: $50/form
Mailed prescriptions of Stimulant medications: $50
Phone sessions may be conducted for Psychotherapy or Medication Management visits, but will be
charged at the usual rate (either as above or per insurance agreements).
Attendance at meetings with other professionals, as arranged by the patient, will incur a pro-rated fee of
$300/hour.
Service payment in full or service co-payments are required to be paid at each session unless alternative
arrangements have been made. Alternative arrangements must be delineated and agreed upon prior to
dates of service. Payment may be rendered by credit card, including Visa, MasterCard, or Discover, by
personal check or by cash.
Patients who pay at the time of service may receive a brief billing receipt from me at the time of payment.
Patients may also ask for a more detailed receipt that includes a code for the type of service rendered and
a code for the clinical diagnosis. This detailed receipt is required by insurance companies in order to
process an “out-of-network” reimbursement (see below). If a patient receives a bill of charge for my
services, it will include the more detailed receipt.
Any check returned for insufficient funds will be assessed a service charge of $20.00.
I may use an attorney or collection agency to retrieve an unpaid balance that is older than 90 days. If this
occurs, the patient will be responsible for the attorney and/or collection fees as well.
January 2016
Amanda S. Kleinman M.D.
Insurance
Amanda S. Kleinman, M.D. is only contracted to work (“in-network”) with Blue Cross/Blue Shield’s PPO
network. By signing this document, patients using their insurance for payment of services authorize
Amanda S. Kleinman to share clinical information with the insurance company, including psychiatric
diagnoses, if such information is requested for reimbursement processing or medication authorization.
Amanda S. Kleinman, M.D. is NOT affiliated (“out-of-network”) with all other insurance plans and
providers, including Medicare and Medicaid. Some commercial insurance plans may partially reimburse
patients receiving services from “out-of-network providers.” Patients should call their insurance company
to find out if they have an “out-of-network benefit” for Outpatient Mental Health services and how to
make use of it. In most cases, patients may take the receipts they receive from me at the time of service
and submit them to the insurance company for the partial reimbursement.
Medicare and Medicaid are forms of government insurance and will NOT reimburse any services provided
by Dr. Kleinman. Patients must NOT send ANY billing receipts from Dr. Kleinman to either of these
entities.
Agreement for Treatment
It is understood that services provided may include assessment, psychotherapy (individual, couples, or
family), medications, referral for psychological testing or other assessments or ancillary treatments as
deemed necessary.
I have read this treatment agreement. I have received satisfactory answers to all questions I have asked
regarding its contents. I agree to abide by the terms set forth in this agreement.
Print Name
Signature
Date
January 2016