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Informed Consent for Psychometric QB Testing and Advance notice of payment

QbTest is an objective computer administered test to guide diagnosis for individuals that are struggling with symptoms of attention deficit hyperactivity disorder / attention deficit disorder (ADHD/ADD). This is usually done in combination to an initial assessment/clinical interview, and completion of written questionnaires.
Psychological evaluation measures the following: hyperactivity, impulsivity, and inattention.
Testing requirement and Payment: All participants needing medication initiation after QB testing report will need to schedule an initial assessment to guide medication initiation and management.
Psychometric testing involves administering, scoring and interpretation of the testing report. The fee for this psychometric QbTest is $250.00.
Insurances and Reimbursement: Some insurance plan may or may not cover QbTest fee. Some insurance companies reimburse at different rates. Be informed that you are responsible for the full amount of this QbTest if submission of claims to your insurance company gets denied.
Your signature below indicates that you have read the information and agree to abide by its terms.
By your signing your signature below, you indicate that: You have been informed of this agreement and understand the type of testing being provided. You understand and agree to the payment policy. You accept full responsibility for all fees incurred in completing this Psychometric test.

Name of Patient (if over the age of 18 years of age):

Signature of Patient or Parent/Guardian, if applicable:

Printed Name Relationship to Patient:

Signature Date:

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.

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