847.298.6446 • Fax: 847.298 - Neurofeedback › pdf › Office_Policies.pdfJoseph N. O’Donnell, PH.D Samer Effarah, Psy. D Yana S. Ludena, CADC OFFICE POLICY: The following paragraphs

OFFICE POLICIES

1400 East Golf Road, Suite 105, Des Plaines, IL 60016955 North Plum Grove Road, Suite D, Schaumburg, IL 60173

847.298.6446 • Fax: 847.298.6447www.NeurofeedbackTherapyChicago.com

Joseph N. O’Donnell, PH.DSamer Effarah, Psy. D

Yana S. Ludena, CADC

OFFICE POLICY:The following paragraphs provide information and outline our policies at Joseph N. O’Donnell & Associates, Inc.Please read all the items below and state that you agree to abide by our policies by initialing sections noted andsigning at the bottom of page 2. If you have a question concerning any item, let us know, so that we may clarify itbefore you sign.

OFFICE HOURS:Hours at our Des Plaines office are Monday, Wednesday, and Friday from 9:00 A.M. to 5:00 P.M. and Tuesday andThursday  from 11:00 AM to 6:00 PM. Hours at our Schaumburg office are Monday and Wednesday byappointment only. Only the Schaumburg office is open on Saturdays and appointments are scheduled by Yana.Please note: Office hours are subject to change without prior notice.

APPOINTMENTS:Our schedule is by appointment only and we make a sincere attempt to adhere to our schedule. However, theremay periodically be a delay in seeing you as a result of emergencies or unforeseen circumstances with treatment ofanother patient. When this happens, your patience is appreciated.  If we are significantly behind schedule, thereceptionist will advise you so that you may determine whether you wish to wait or reschedule.

• Please be on time for your appointments.  If you are late, it inconveniences  the patients who are scheduledafter you by delaying their treatment.

• During treatment family members must remain outside of the treatment room, unless otherarrangements have been made.

• Family members should maintain appropriate noise levels while the patient(s) is/are being treated.

LATE, CANCELLATION, and MISSED APPOINTMENTS:If you cannot keep an appointment, at least ONE (1) BUSINESS DAY prior notice should be given to our office tocancel or move your appointment. This courtesy on your part makes it possible to give your appointment toanother patient who desires treatment. If adequate notice is not given, a $50 late or missed appointment fee willbe added to your account.

Patient or Guarantor’s  Initials ________

OFFICE POLICIES





INSURANCE:As a courtesy to you, our office will bill your primary insurance carrier on a regular basis. Because of the time andexpense involved, we do not bill secondary or supplemental  insurance. We do not honor any PPO discounts fromPPO insurance that we are not a provider for, nor for your secondary insurance carriers. Illinois law allows 30 daysfrom receipt for a claims complete processing, however as a courtesy our office allows 60 days on processing yourclaim(s). After this 60 day period our office will need to collect payments from patient(s) for any pending claimamount. If you receive payments from your insurance carrier, it will be your responsibility to see that thesepayments are forwarded to our office, along with the explanation of benefits (EOB). The amount your insurancecompany pays has no bearing on your financial obligation to us. It is your responsibility to pay any deductibles orother balances not paid by your insurance. Payment for all non‐covered services or other items is due at the timethey are rendered or purchased, unless prior arrangements have been made.


SELF PAY POLICY:It is your responsibility  to pay the account balance. Payment for all services or other items is due at the time theyare rendered or purchased, unless prior arrangements have been made.   


RETURNED CHECKS:There is a $25 fee for each returned check.  This fee will automatically be added to your account.


CHARGES FOR REPORTS:If your insurance company requires a report to determine benefits, there will be a charge for this report. However,since most insurance companies will not pay for the report that they request, you will be notified in advance ofwhat the charge will be.


OFFICE POLICIES





COLLECTIONS:I understand that I am responsible for the cost of postage for any certified letters sent to me and if for any reasonmy account goes to a collection agency you can and will collect the collection fee in addition to my unpaidbalance.


I UNDERSTAND AND AGREE TO ABIDE BY THE ABOVE OUTLINED OFFICE POLICIES.

Patient name ______________________________________________

Patient or Guarantor’s Signature ____________________________________ Date ____________________

Printed Name ______________________________________________ Relation to patient ________________(If Guarantor is signing for patient)

Documents

847.298.6446 • Fax: 847.298 - Neurofeedback › pdf › Office_Policies.pdfJoseph N. O’Donnell, PH.D Samer Effarah, Psy. D Yana S. Ludena, CADC OFFICE POLICY: The following paragraphs