Germantown Psychological 7516 Enterprise Avenue, Suite 1

Germantown, TN 38138
Associates, P.C. Tel: 901-755-5802
www.germantownpsych.com Fax: 901-757-2249

Psychologists Clinical Social Workers

Richard L. Luscomb, Ph.D., MSCP Karen D. Sanders, LCSW
Roy D. Greenberg, Ph.D. ________________
Alicia L. Autry, Ph.D.
Medical Consultant
Kaylee A. Bruijn, Ph.D. Clinician:  Luscomb  Greenberg  Sanders  Autry Jeffrey H. Lowrey, M.D.
Elizabeth C. Shmikler, Ph.D.
.  Bruijn  Shmikler

This letter is your confirmation for your initial appointment at Germantown Psychological Associates.

Your appointment information:  Telehealth  At our office

Riley Wack
Individual Scheduled: _________________________________

12/01/23
Date: _________ 11:30 am
Time: ________ PLEASE NOTE: If the patient is a minor, a parent
must be present for the first part of the session.

In order to keep the above appointment in our schedule, we will need the
attached paperwork completed and returned to us within 72hrs of receipt.

IMPORTANT INSTRUCTIONS—PLEASE READ!

1. There are several forms included in this email that you will need to complete. Click DONE when all forms are
completed; follow instructions to return to us.

2. If you are 18-25 years old and are covered by your parent’s insurance, you will need to sign the Registration
Form as Patient and your parent will need to sign as Responsible Party for financial reasons.

3. Please go to our website: www.germantownpsych.com to Forms and print off the Child, Adolescent, Young
Adult History Form (ages 1-23) OR the Adult History Form, depending on the age of the patient. Complete and
return to us by US Mail, drop off at our office, or email to us at: GPAhistoryforms@gmail.com. DO NOT FAX

4. If you need to cancel or reschedule your appointment, please call our office with 48 hours notice (and on Friday
for Monday appointments). If you cancel or reschedule with less than 24 hours notice, a missed appointment fee
will be charged.

5. If your appointment is via Telehealth, your Clinician will email you a link to the Telehealth Platform they are
using on the day before or same day of your appointment. We will help you if you have difficulty connecting.

6. If you have any questions, please call our office and speak with our staff.

Thank you,

Germantown Psychological Associates, P.C.

GPA,PC: 04-20-2023
 Germantown Psychological 7516 Enterprise Avenue, Suite 1 Clinician:______________
Germantown, TN 38138
Associates, P.C. Tel: 901-755-5802 _________
www.germantownpsych.com Fax: 901-757-2249

Ellyn or Greg Wack- Parents

Riley Wack
Patient: ________________________________ Emergency Contact Person – Relationship to Patient
7
AGE: _______ DOB: 03/07/2016
_________________ 901-494-1136 or 901-604-6376

TN
State of. Residence: _______________________ Cell Phone Number of Emergency Contact

901-494-1136 or 901-604-6376
Cell Phone: _____________________________ If PATIENT is under the age of 18, we must have the parent’s cellphone
and email address below:
ewack@live.com
Email: _________________________________
901-494-1136 ewack@live.com
Cell Phone: ______________ Email: ________________________________

Informed consent for Telehealth services

What is Telehealth: Telehealth means, in short, provision of mental health services with the provider and
recipient of services being in separate locations, and the services being delivered over electronic media.

➢ There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.
➢ Confidentiality still applies for telehealth services, and there will be no recording of sessions.
➢ We will use the agreed upon video-conferencing platform selected for our virtual sessions, and the Clinician will explain how to use
it.
➢ You need to use both audio and visual. This means a computer with a webcam, an iPad, or a smartphone during the session.
Make sure that they are either fully charged and/or plugged in during the session.
➢ It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
No other individuals are allowed to be in the room or enter the room during the session.
➢ It is require that you use a secure internet connection rather than public/free Wi-Fi.
➢ It is important to be on time for your session. If you need to cancel or change your tele-appointment, you must notify the therapist
in advance [24 hours] by phone at: 901-755-5802 and leaving a message specific to your therapist.
➢ We need a back-up plan (e.g., phone number where you can be reached) to complete the session or to reschedule it, in the event
of technical problems.
➢ We will need to develop a safety plan together. You will also need to provide at least one emergency contact in the event of a
crisis situation.
➢ You will need to confirm with your insurance company that the Telehealth video sessions will be reimbursed; if they are not
reimbursed, you are responsible for full payment.
➢ As your therapist, it is my responsibility to determine that [due to certain circumstances] telehealth is no longer the most
appropriate form of therapy and to decide that we should resume our sessions in-person.
……. If you have any questions, please speak with your Clinician.

11/28/2023
Patient _______________________________________________________________ Date ________________

[If the patient is either under age or has a guardian appointed by the court, this release must be signed by the patient’s parent or guardian
also]

11/28/2023
Parent/Legal Guardian ______________________________________________________ Date ________________
Parent
Relationship to Patient: _______________________ ewack@live.com
Parent/Legal Guardian’s EMAIL: ___________________________________

GPA,PC: FORM - Telehealth Informed Consent 12-21-2020

 Germantown Psychological
Associates, P.C.
7516 Enterprise Avenue, Suite 1
Germantown, TN 38138
Tel: 901-755-5802
V
Fax: 901-757-2249
www.germantownpsych.com

Registration Information
PATIENT INFORMATION

Patient Legal Name: Riley Paige Wack

____________________________________________ SS# 670987923 Sex: Male Female ________

[If patient goes by a different first name: ________________________]

03/07/2016
Date of Birth: _______________ Age:7______ Marital Status: Single Married Separated Divorced Widowed
Home Address: 3552 Earlynn Dr Bartlett TN 38133
___________________________________________City:________________________State:________ZIP:_________
901-494-1136
Home Phone: [________]_______________________Cell 901-604-6376
Phone: [________]___________________ Prefer: Home Cell Work
901-604-6376
Daytime number where you may be reached regarding appointments: [_______]___________________________
Occupation: -___________________________________ Oak Elementary
Student – Name of school: _________________________________
-
Employer: ___________________________________ -
Work Phone: [________]_________________
-
Employer Address: __________________________________________________________________________________
Patient’s E-mail Address: ewack@live.com or gregwack1024@gmail.com
_______________________________________________ [Please put Parent’s email if patient is under 18]
RESPONSIBLE PARTY or SPOUSE’S INFORMATION
Name: Jessica Ellyn Powers-Wack
_________________________________________ Parent
Relationship to Patient: _____________________________________
SS# 408613071 02/01/1987
Date of Birth: ________________ 36
Age: ____________
Home Address: 3552 Earlynn Dr Bartlett TN 38133
___________________________________________City:________________________State:________ZIP:_________
901-494-1136
Home Phone: [_________]______________________Cell 901-604-6376
Phone: [________]_________________ Prefer: Home Cell Work

Occupation: Teacher
___________________________________________
Bartlett City Schools
Employer: ____________________________________________ 901-494-1136
Work Phone: [______]______________________
Woodlawn Bartlett, TN 38134
Employer Address: ______________________________________________

----------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr. Elisa Benaim Dr. Elisa Benaim
Provider of Previous Treatment: ______________________________ Referred by: ________________________________________

________________________________________________________
I will NOT be utilizing insurance for services at GPA, PC

I am utilizing insurance for services at GPA, PC – If you check this box, please fill out the following section completely.

Jessica Ellyn Powers-Wack

Insured/Responsible Party [If other than patient]: ________________________________________________
Parent
Insured’s Relation to Patient: ________________ 02/01/1987
Insured’s Date of Birth: ____/____/_______
MedBen
Insurance Company: _______________________________________________________________________
PO Box 1099, Newark, OH 43058
Insurance Company’s Address: _______________________________________________________________
Bartlett City Schools
Insured’s Place of Employment: ________________________ 10488-00203
I.D., Policy, or Group No.: ________________

If the patient is less than 18 years of age, I attest that I am the legal guardian and have authority to initiate treatment for my child:

YES NO Signature ______________________________

Patient or Responsible Party Initials

© GPA, P.C. – Revised 6/28/2022 kds/rll

 GPA Registration Information – Page Two

PATIENT INFORMATION
The following information is being provided so that you will have an understanding of the conditions of your therapy. Please
read this carefully, and feel free to ask questions about anything that seems unclear. Your signature indicates your consent and agreement
to these conditions.

TYPE OF PRACTICE
Germantown Psychological Associates, P.C. (GPA) offers outpatient therapy and psychological services that include, but are not
limited to: evaluation, individual and group therapy, marital and couples therapy, family therapy, divorce counseling, adolescent and
child/pediatric psychology, psychological testing, health psychology, biofeedback training, and stress management training. The decision
as to which type of therapy to use will be decided jointly with you after an initial assessment. Should services that we do not provide
appear indicated, we will be glad to suggest other options and make referrals for you.

Practitioners do not provide any medication or perform any medical treatments. We maintain consulting relationships with
physician colleagues in the event that medical treatment/evaluation is indicated as an adjunct to therapy. In the event that inpatient
treatment appears indicated, we will assist you with an appropriate referral with your permission and signed consent.

PSYCHOTHERAPY
Psychotherapy is designed to help people increase their understanding and awareness of problem areas and to learn more
effective methods of dealing with these issues. There are potential risks as well as potential benefits. Psychotherapy may involve the risk
of remembering unpleasant events and experiencing intense emotions. People sometimes report feeling worse before feeling better, and
in personal relationships (e.g. marital relationships) it is possible for one party to develop or change in such a way as to grow apart from
his or her partner, and thus weaken or dissolve the relationship.

The potential benefit from psychotherapy may be the ability to handle or cope with the stress and problems in your life and
experience more satisfaction from relationships. You may also gain a better understanding of your personal goals and values, leading to
greater maturity and personal growth, increased general satisfaction with life, and an improved sense of “well-being”.

Therapy is an endeavor that requires much effort, and though we provide our time and our professional knowledge and services,
we cannot promise or guarantee specific results. We feel strongly about providing you with quality care and consequently we will
regularly review with you your goals and progress in therapy. At any time, you have the right to decide not to receive our services and to
end our work together. There is no moral, legal, or financial obligation other than to pay for services already rendered. We do encourage
you to discuss your decision to terminate with your therapist. If you wish, we can provide you with the names of other mental health
professionals.

CONFIDENTIALITY
Within the limitations discussed below, all information revealed by you during our professional relationship will be kept
confidential and WILL NOT be released to anyone without your WRITTEN CONSENT. However, under the following
circumstances, we may be required to breach confidentiality: 1) if you present a danger to yourself or to others, which includes
communicable diseases that can be life-threatening to others; 2) if we have reason to believe that child abuse/neglect or domestic violence
has occurred or is present; 3) if treatment is ordered by or under supervision of the courts; or 4) if a legitimate court order is issued.

Additionally, insurance companies and managed health care organizations representing third-party payers often require you to
consent to release records and/or information (including, but not limited to diagnosis, type of services rendered, dates of service, treatment
plans, and other related confidential information) to them as a condition for reimbursement. Your signature(s) below indicate(s) your
permission to release information requested by your insurance company or its representative. When such information is revealed to
insurance companies or managed health care organizations, we cannot control how the material is treated. Information revealed in marital
therapy is also protected by privileged communication, which requires permission of both to waive. In order to provide for consultation
and emergency coverage, the psychologists/therapists affiliated with Germantown Psychological Associates, P.C. do discuss patients
among themselves unless you specify otherwise. If because of nonpayment of your bill we pursue legal remedies, the financial aspects of
your relationship with us will not be considered confidential.

Patient or Responsible Party Initials

2
 GPA Registration Information – Page Three

APPOINTMENTS CANCELATION POLICY

Patients are seen by appointment only. When you make an appointment, the clinician is setting aside that time just for you.
Should a conflict arise that will result in you needing to change a scheduled appointment, please notify our office. GPA, PC
requires that cancellations for scheduled appointments be received at least 24 hours in advance during regular office hours
[Monday through Friday 9:00 am to 5:00 PM]. If you need to call and leave a message of a future cancellation after hours, you
may leave it on the after hours voicemail. It needs to be received at least 24 hours in advance of the scheduled appointment.
Cancelled appointments that do not follow this policy will result in a missed appointment fee being charged. Please remember that
insurance companies do not pay for a missed appointment. In the event of extremely bad weather (e.g., snow and ice), it is advisable to
call our office before you leave home to determine if the office is open.

TELEPHONE CALLS
We attempt to be reasonably available for telephone calls, but when in session with patients, we cannot be interrupted for
incoming calls. We can usually be reached through our office or our after hours phone service in case of emergencies. However, the
telephone is not the manner in which to deal with therapy issues, and telephone consultations exceeding five minutes will be charged
at the normal therapy fees and are not be covered by your insurance.

FINANCIAL CONSIDERATIONS

Services Usually Covered By Insurance

Standard operating hours for Germantown Psychological Associates, P.C. are 9:00 a.m. to 5:00 p.m. Monday through Friday.
Sessions conducted outside of these designated time periods may have after-hour charges that exceed the normal charges.

Psychological testing is often requested by the clinician in order to facilitate treatment planning and progress in therapy. Testing
fees are based on time required for assessment, tests administered, interpretation, and report writing. The testing fees cover the cost of
testing and writing a report. Subsequent sessions to review the results in more detail and/or discuss intervention strategies are charged at
regular session fees. When psychological testing is requested, a separate appointment will be made for you by the office. Testing fees
must be paid in full prior to the evaluation.

Services Not Covered By Insurance

Should a request be made of your clinician that he/she become involved in legal matters (e.g., giving testimony, deposition, etc.),
the fee for such activity is $300.00 per hour for preparation and review of materials and then $450.00 per hour for all other time involved,
to include, but not limited to, travel time, court time, and any other time involved. A retainer fee based on the estimated time involved
will be charged, to be paid 4 business days in advance, with the minimum including $600.00 for two hours of preparation along with
$1,350.00 for three hours of deposition/testimony/travel time/court time for a total of $1,950.00. If the deposition or court hearing is
cancelled less than two business days before the scheduled time, the minimum charge payment of $1,500.00 will be forfeited from the
retainer fee and $450.00 from the retainer fee will be reimbursed. NOTE: Clinical work for the specific purpose of involvement in civil
cases, custody evaluations, mediation and criminal cases may require a separate agreement and fee schedule different from the above.

Letters, treatment summaries, copies of treatment records, and psychological testing reports are sometimes generated and
released to patients, other professionals and insurance companies. Tennessee law and the ethical principles promulgated by the American
Psychological Association govern the release of such written communication. Appropriate releases must be signed.

A written request form for the release of information is available from the receptionist and is required to begin the process of
obtaining information. Written requests help ensure that information released is what was requested and that it is sent to the appropriate
individual/agency. The standard turn-around time for request for written information is ten (10) business days. Urgent or
“emergency” requests shall incur a surcharge to be paid before the information is released.

A separate fee will be assessed for generating letters, treatment summaries, or other written communications outside the regular
therapy session. These charges, as well as surcharges for “Urgent” requests, will vary depending on the complexity of and time required
to complete the request.

Due to the cost of transfer of old records into storage after being inactive twelve months, along with maintenance of stored
records, any requests for copies of records and treatment after this time period will incur a specific fee related to storage and retrieval.
Arrangements can be made to pick up requested records. An additional fee for FedEx delivery will be charged if the individual requests
that the records be delivered. Records are only maintained for a specified period of time.

3 Patient or Responsible Party Initials

 GPA Registration Information – Page Four

BILLING

As a courtesy to our patients, our office will file insurance claims for you. However, due to the complexity of insurance and
billing, our office will not “back file” any insurance claims. Patients who have health care insurance should remember that
professional services are rendered and charged to the patient and not to the insurance company. We cannot accept responsibility for
collecting your insurance claim or for negotiating a settlement on a disputed claim. Regardless of the action of your insurance
company, you are responsible for your bill. Co-payments are due at the time of service. Patients are requested to have a credit
card on file with permission to charge session fees at the time of service. Otherwise, patients are requested to provide payment at
time of service. GPA, PC does not carry balances on accounts.

Our Responsibility to Report Non-Compliance: Under many managed care contracts, it is the provider’s obligation to report
patients who refuse to pay co-pays and deductibles at the time of service or patients who repeatedly “no show” for appointments. We
have reserved the right to take this action. Please understand that if you are reported, you could lose your insurance benefits. You can
contact your Human Resources department or your insurance company for further information on this matter.

Though we make every effort to keep costs down, fees may change over the course of your treatment. You will be responsible
for the increased fees. For individuals who are not covered by health care insurance, the full balance is due and payable at the time of
service. There will be a billing fee of $5 per month after 60 days. There will be a $30 service charge on all returned checks. If this
account is litigated or turned over to an attorney for collection by suit or otherwise, the patient (or responsible party undersigned) agrees
to pay all costs of collection and litigation, together with a reasonable attorney’s fee.

PATIENT AGREEMENT
Having read the foregoing information fully and completely, I have discussed any questions I had about the information with my
therapist or an employee of Germantown Psychological Associates, P.C. and I understand the information fully with respect to the
proposed treatment. I understand and accept the risks inherent in the course of therapy proposed for me.

I have familiarized myself with the fees and charges for services provided by Germantown Psychological Associates, P.C. I
understand and agree that the services to be rendered will be charged to me and not to any insurance company or third-party payer. I
understand that Germantown Psychological Associates, P.C. will bill me for professional services rendered in accordance with the
information set out above, and I acknowledge my responsibility for payment for such services; moreover, I understand that I am
responsible for all costs of collection and litigation together with a reasonable attorney’s fee if the charges for services rendered to me
must be collected by an action at law.

I consent and agree that Germantown Psychological Associates, P.C. may release such information as may be required by my
insurance company or managed health care organization for payment for services rendered for me. I agree to hold Germantown
Psychological Associates, P.C. harmless for any injury or claim for damages arising from release of records or information as required by
my insurance company or managed health care organization.
11/28/2023
Patient (s) _______________________________________________________________ Date ________________

11/28/2023
Responsible Party/Guardian _________________________________________________ Date ________________
Signature

Printed Name of Responsible Party/Guardian: Jessica Ellyn Powers-Wack

______________________________________________________

[The above Responsible Party/Guardian line must be signed by the person who is assuming full financial responsibility for all fees
incurred for this account]

Emergency Contact Information

Please identify an individual below who you give us permission to contact in the event of an emergency with you or your
child:
Donna Powers 901-734-5058 Grandparent
Name:___________________________Phone:___________________Relationship:__________________

This Registration Form was reviewed by:

4 © GPA, P.C. – Revised 6/28/2022 kds/rll
________________________ [STAFF]
 Germantown Psychological 7516 Enterprise Avenue, Suite 1
Germantown, TN 38138
Associates, P.C. Tel: 901-755-5802
www.germantownpsych.com Fax: 901-757-2249

Psychologists Clinical Social Workers

Richard L. Luscomb, Ph.D.,MSCP Karen D. Sanders, LCSW
Roy D. Greenberg, Ph.D.
________________
Alicia L. Autry, Ph.D.
Medical Consultant
Kaylee A. Bruijn, Ph.D.
Jeffrey H. Lowrey, M.D.
Elizabeth C. .Shmikler, Ph.D.

Due to the COVID-19 impact on our community, we have moved to a touchless payment system in
order to increase our ability to provide services safely as well as hold down costs. In order to do so, we
will need to have a credit card on file to take care of your payments. This information will be securely
stored in our HIPAA compliant/Encrypted system.

If you would, please feel out this Credit Card Authorization. Plesase contact our office
should you wish to change the card we have on file or you need to update the information on the card.

CREDIT CARD AUTHORIZATION

Riley Wack
Patient Name:___________________________Account #__________

Clinician:  Luscomb  Greenberg  Sanders  Autry  Bruijn  Shmikler

Card Type  VISA  MasterCard  Discover

Ellyn Powers-Wack
Cardholder Name (name on card):____________________________________________
[Please Print Clearly]
4355 4607 0489 5985
Card number:_____________________________________________
01/26
Expiration Date: _____ /________
MM YY

038
CCV number (on back of card) _________
3552 Earlynn Dr Bartlett TN 38133
Cardholder full address:_________________________________City_____________ST____ZIP_________
Jessica Ellyn Powers-Wack
I, _________________________________authorize GPA, PC to charge my credit card above for agreed
upon charges, to include session fees and co-pays. I understand that my information will be saved to file
for future transactions on my account.

_________________________________________________________ 11/28/2023
Date:_______________
Signature of cardholder DD/MM/YYYY

STAFF: ________
GPA,PC: FORM – 04-20-2023
08/04/2017

Notice of Germantown Psychological Associates, P.C. Policies and Practices to Protect the Privacy
of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY. FOR THE PURPOSES OF THIS NOTICE, GPA, PC WILL REFER TO
GERMANTOWN PSYCHOLOGICAL ASSOCIATES, P.C. AND ITS CLINICAL STAFF.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
GPA, PC may use or disclose your protected health information (PHI), for treatment, payment, and health care
operations purposes with your consent. To help clarify these terms, here are some definitions:

 “PHI” refers to information in your health record that could identify you.
 “Treatment, Payment and Health Care Operations”
– Treatment is when GPA, PC provides, coordinates or manages your health care and other services related to
your health care. An example of treatment would be when GPA, PC consults with another health care provider,
such as your family physician or another psychologist.
– Payment is when GPA, PC obtains reimbursement for your healthcare. Examples of payment are when GPA,
PC discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine
eligibility or coverage.
– Health Care Operations are activities that relate to the performance and operation of GPA, PC’s practice.
Examples of health care operations are quality assessment and improvement activities, business•related matters
such as audits and administrative services, and case management and care coordination.
 “Use” applies only to activities within GPA, PC such as sharing, employing, applying, utilizing, examining, and
analyzing information that identifies you.
 “Disclosure” applies to activities outside of GPA, PC, such as releasing, transferring, or providing access to
information about you to other parties.

II. Uses and Disclosures Requiring Authorization

GPA, PC may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your
appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent
that permits only specific disclosures. In those instances when GPA, PC is asked for information for purposes outside of
treatment, payment and health care operations, GPA, PC will obtain an authorization from you before releasing this
information. GPA, PC will also need to obtain an authorization before releasing your psychotherapy notes.
“Psychotherapy notes” are notes your therapist has made about your conversation during a private, group, joint, or
family counseling session, which he/she has kept separate from the rest of your medical record. These notes are given a
greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in
writing. You may not revoke an authorization to the extent that (1) GPA, PC has relied on that authorization; or (2) if the
authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to
contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

GPA, PC may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse: If your GPA, PC has knowledge of any child who is suffering from or has sustained any wound, injury, or
disability, or physical or mental condition of such a nature as to reasonably indicate that it has been caused by brutality,
abuse, or neglect, GPA, PC is required by law to report such harm immediately to Tennessee Department of Children’s
Services or to the judge having juvenile jurisdiction, or to the office of the sheriff or the chief law enforcement official of
the municipality where the child resides. Also, if GPA, PC has reasonable cause to suspect that a child has been sexually
abused, GPA, PC must report such information, regardless of whether the child has sustained any injury.
HIPAA – PAGE TWO

 Adult and Domestic Abuse: If GPA, PC has reasonable cause to suspect that an adult has suffered abuse, neglect,
or exploitation, GPA, PC is required by law to report such information to the Tennessee Department of Human
Services.
 Health Oversight: If a complaint is filed against a therapist with the Tennessee Division of Health Related Boards,
the Board has the authority to subpoena confidential mental health information from GPA, PC relevant to that
complaint.
 Judicial or administrative proceedings: If you are involved in a court proceeding and a request is made for
information about the professional services that GPA, PC has provided you and/or the records thereof, such
information is privileged under state law, and GPA, PC must not release this information without your written
authorization or a court order. This privilege does not apply when you are being evaluated for a third party or where
the evaluation is court ordered. GPA, PC must inform you in advance if this is the case.
 Serious Threat to Health or Safety: If you communicate to a therapist an actual threat of bodily harm against a
clearly identified victim, and your therapist has determined or reasonably should have determined that you have the
apparent ability to commit such an act and are likely to carry out the threat unless prevented from doing so, GPA, PC
is required to take reasonable care to predict, warn of, or take precautions to protect the identified victim from your
violent behavior.
 Workers' Compensation: If you file a worker's compensation claim, and your therapist is seeing you for treatment
relevant to that claim, GPA, PC must, upon request, furnish to your employer or insurer, and to you, a complete
report as to the claimed injury, the effect upon you, the prescribed treatment, and estimate of duration of
hospitalization, if any, and a statement of charges.

IV. Patient's Rights and GPA, PC’s Duties

Patient’s Rights:
 Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of
protected health information about you. However, GPA, PC is not required to agree to a restriction you request.
 Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have
the right to request and receive confidential communications of PHI by alternative means and at alternative
locations. (For example, you may not want a family member to know that you are seeing a therapist. Upon your
request, GPA, PC will send your bills to another address.)
 Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health
and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your
request, GPA, PC will discuss with you the details of the request process.
 Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the
record. GPA, PC may deny your request. On your request, GPA, PC will discuss with you the details of the
amendment process.
 Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding
you. On your request, GPA, PC will discuss with you the details of the accounting process.
 Right to a Paper Copy – You have the right to obtain a paper copy of the notice from GPA, PC upon request,
even if you have agreed to receive the notice electronically.

GPA, PC’s Duties:

 GPA, PC is required by law to maintain the privacy of PHI and to provide you with a notice of GPA, PC’s legal
duties and privacy practices with respect to PHI.
 GPA, PC reserves the right to change the privacy policies and practices described in this notice. Unless GPA, PC
notifies you of such changes, however, GPA, PC is required to abide by the terms currently in effect.
 GPA, PC reserves the right to change the terms of this notice and to make the new notice provisions effective for all
PHI that it maintains. If GPA, PC revises policies and procedures, GPA, PC will provide you with a revised notice.

V. Complaints
If you are concerned that GPA, PC has violated your privacy rights, or you disagree with a decision GPA, PC made
about access to your records, you may contact: HIPAA Officer, 7516 Enterprise Ave., Suite 1, Germantown, TN 38138.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The
person listed above can provide you with the appropriate address upon request.
Germantown Psychological 7516 Enterprise Avenue, Suite 1
Germantown, TN 38138
Associates, P.C. Tel: 901-755-5802
Fax: 901-757-2249

Psychologists Clinical Social Worker

Richard L. Luscomb, Ph.D., MSCP Karen D. Sanders, LCSW
Roy D. Greenberg, Ph.D. Protected Health Information
________________
Alicia L. Autry, Ph.D. Acknowledgment Form Medical Consultant
Kaylee A. Bruijn, Ph.D.
Jeffrey H. Lowrey, M.D.
Elizabeth C. Shmikler, Ph.D.
.

Clinician: RLL RDG KDS ALA KAB ECS

Riley Wack
Patient Name:__________________________
GPA ACCOUNT #: ____________________

You should review the Notice of Privacy Practices regarding Germantown Psychological Associates, P.C.’s
Policies and Practices to Protect the Privacy of your health information prior to signing this sheet.
May the GPA, PC staff leave messages regarding your health care on your HOME voicemail or answering machine?
 YES  NO

May the GPA, PC staff leave messages regarding your health care on your CELL PHONE voicemail and TEXT? [At
some time in the future, this may include notification/reminder of upcoming appointments]. NOTE:
TEXT is not encrypted and thus,
is not a HIPAA secure form of communication.
 YES  NO

May GPA, PC clinicians communicate with you regarding health care issues through your E-Mail. NOTE: E-Mail
is not encrypted and thus, is not a HIPAA secure form of communication. Your E-Mail address will not be shared
with any other practice, clinic or person outside of GPA, PC.
 YES  NO

ewack@live.com Jessica Ellyn Po

E-Mail Address: _________________________@____________________ Who has access to this E-Mail? ________________
Individuals to whom information may be disclosed in the event Germantown Psychological Associates, P.C. cannot reach you - information
regarding appointments may be discussed and/or released to:
Donna Powers Grandparent
Name of Person: ______________________________________________ Relationship to Patient: __________________________________________
901-734-5058 - -
Home Phone: [ ] ____________________ Cell Phone: [ ] ____________________ Work Phone: [ ] ____________________
Mike Powers Grandparent
Name of Person: ______________________________________________ Relationship to Patient: __________________________________________
901-827-3326 - -
Home Phone: [ ] ____________________ Cell Phone: [ ] ____________________ Work Phone: [ ] ____________________

I hereby acknowledge that I have reviewed the Notice of Germantown Psychological Associates, P.C. Policies and Practices to Protect the Privacy of
Your Health Information as well as the above consent information contained on this form and give my permission to GPA, PC to use and disclose my
health information in accordance with it:
Riley Paige Wack
Print Patient’s Full Name: _______________________________________________
11/28/2023
Signature of Patient [or Parent if Minor Child]: ____________________________________ Date: ________________
Jessica Ellyn Powers-Wack
Print Parent Name if Minor Child: ________________________________________

Signature of Witness [GPA Staff Member]: __________________________________________________________ Date: __________________

HIPAA Acknowledgement -04-20-2023

Germantown Psychological 7516 Enterprise Avenue, Suite 1
Germantown, TN 38138
Associates, P.C. Tel: 901-755-5802
Fax: 901-757-2249
www.germantownpsych.com

Psychologists
Richard L. Luscomb, Ph.D.,MSCP Patient Name: Riley Wack Clinical Social Worker
Karen D. Sanders, LCSW
Roy D. Greenberg, Ph.D.
Alicia L. Autry, Ph.D.
Responsible Party: Jessica Ellyn Powers-Wack ________________
Medical Consultant
Kaylee A. Bruijn, Ph.D. Clinician:  Luscomb  Greenberg  Sanders  Autry Jeffrey H. Lowrey, M.D.
Elizabeth C. Shmikler, Ph.D.

. Bruijn  Shmikler

Patient Responsibility Checklist

In an effort to better serve our patients, we work hard to communicate clearly the financial relationship between
Germantown Psychological Associates, P.C. and you. Three areas have been identified that need to be addressed
at the beginning of our relationship: Missed appointments, other Non-Insurance Covered Charges and
Payment for Services at the time of the appointment. Before signing below, please be sure that you
understand the guidelines that the Board of Directors for GPA, PC have set up for these areas. Thank you.

Payment: I understand that I am expected to pay for services at the time they are provided. We do not carry
balances. All testing must be paid for in advance. Signing as responsible party, I accept that I am
responsible for all fees, regardless of what a divorce decree may state. GPA, PC has no authority to bill
another party who has not signed the registration form as financial responsible party.

Missed Appointments: Missed appointments as well as those appointments cancelled with less than 24 hours
notice will be charged as a Non-Insurance Covered Charge. You are responsible for this charge and it
will not be filed with your insurance company.

Non-Insurance Covered Charges: The following services will result in a “Non-Insurance Covered Charge”
which means that insurance will not cover them nor will they be filed with your insurance company:

Missed Appointment $95.00

Appointment Cancelled with less than 24hrs notice $95.00
Missed Appointment Related to Testing $225.00
Testing Cancelled with less than 24hrs notice $225.00
Telephone Consult – 15 Minutes $50.00
Telephone Consult – 30 Minutes $110.00
Telephone Consult - 50 Minutes $175.00
Correspondence/Letter – Limited $25.00 - $50.00
Correspondence/Special Report – Extended $175.00 / Hour
School Visit $100.00 - $200.00
Other Non-Insurance Covered Charges $175.00 / Hour
Copies of Psychological Reports after second copy $20.00 each

Jessica Ellyn Powers-Wack

I, ____________________________, agree to be responsible and pay for all “Non-Insurance
Covered Charges” as detailed above.
11/28/2023
____________________________ __________ _______________________
Responsible Party Signature Date Staff Signature
Patient Responsibility Form: 04-20-2023
Germantown Psychological 7516 Enterprise Avenue, Suite 1
Germantown, TN 38138
Associates, P.C. Tel: 901-755-5802 DATE: 11/28/2023
___________
Fax: 901-757-2249

Insurance Verification INFORMATION

1. Look on the back of your insurance card for the phone number to call to get benefits information.

2. When you call the insurance company, you will need to ask for benefits related to “Outpatient Mental Health.”

3. We will not be able to file your insurance unless you provide us with a copy of your Insurance Card.

4. We do not accept CIGNA, UHC, UBH, UMR, Optum, Humana or Lifesynch as your PRIMARY INSURANCE.
If MEDICARE is your primary insurance and you have a supplemental policy administered by one of the above
companies [or any other company], please provide that information under the SECONDARY INSURANCE
portion of this form.

5. If your PRIMARY INSURANCE benefits are administered through CIGNA, UHC, UBH, UMR, Optum, Humana
or Lifesynch, you will be considered a cash patient. If you have any questions, please call our office at (901) 755-
5802.
PRIMARY INSURANCE INFORMATION
[Includes all commercial insurance and Medicare]

Riley Paige Wack 03/07/2016

Patient’s Legal Name: _____________________________________DOB:__________
First Name MI Last Name
MedBen 800-6868425
Insurance Company: _______________________________Phone #: ________________
MB01623538 10488-00203
Subscriber/Policy/ID #: _________________ Group #: ________________

Jessica Ellyn Powers-Wack 02/01/1987

Policy Holder’s Name:_________________________________________DOB:________________
Bartlett City Schools 408613071
Policy Holder’s Employer:_________________________________SS#______________________

Greenberg
Is _________________________ “In Network” and covered by my policy? Yes No
(The clinician’s name that I/my child will be seeing)

MedBen
Who are my mental health benefits administered through?_________________________
0 0 30
Deductible:$__________ Amount already met this year:$_________Co-pay$_________
N/A
Do I have an HRA/HSA? Yes No If yes, what is the current balance? $__________
[HRA – Health Reimbursement Account/HSA – Health Savings Account/FSA - Flexible Spending Account]

Do I need to do Coordination of Benefits?: Yes No If yes, has this been done? Yes No
-
Name of person you spoke with:_______________________________

Use other side for those with SECONDARY INSURANCE POLICY

Ins. Ver: ©GPA – 03-21-2023
 SECONDARY INSURANCE INFORMATION
Insurance Company: _______________________________Phone #: ________________

Subscriber/Policy/ID #: _________________ Group #: ________________

Policy Holder’s Name:_________________________________________DOB:________________

Policy Holder’s Employer:_________________________________SS#______________________

Is _________________________ “In Network” and covered by my policy? Yes No

(The clinician’s name that I/my child will be seeing)

Who are my mental health benefits administered through?_________________________

Deductible:$__________ Amount already met this year:$_________Co-pay$_________

Do I have an HRA/HSA? Yes No If yes, what is the current balance? $__________

[HRA – Health Reimbursement Account/HSA – Health Savings Account/FSA - Flexible Spending Account]

Do I need to do Coordination of Benefits?: Yes No If yes, has this been done? Yes No

Name of person you spoke with:_______________________________

Insurance Verification: ©GPA 03-21-2023