Service Agreement Company Fees and Payment • I understand that all referral and funding documentation must be provided to my clinician on or before appointment dates in order to obtain funding / rebates. This includes re-referrals or updated plans with current clinicians; • I understand and agree to the fee schedule, and that fees are subject to an annual increase on July 1st of each year; • I understand that if my third-party funding is not available, I am required to pay for services; • I understand that prompt payment of invoices will ensure ongoing therapy service provision. I agree to the Talking Works' policy for settling accounts. Settling Accounts o Payment due on or before date of your appointment; o If off site, text or email office your bank deposit receipt to confirm payment; o Full payment is required prior to receiving assessment reports; o Late Payment Fee of $5 applies for payments not made on the day; o Payment options: EFTPOS/Credit Card, Bank Transfer/Deposit; o Mobile & Telehealth sessions require secured credit card details to ensure payment. Cancellation Policy o Late Cancellation Fee (less than 48 hours notice): 50% of full fee + GST o Less than 24 hours notice or Non-Attendance: Full session fee + GST ▪ Please note that Cancellation Fee will be waived if appointment filled; ▪ Alternatively, clinicians can provide a telephone consult, letter, or email during the time of your scheduled appointment; ▪ Cancellations are not eligible for Medicare or insurance rebates. I agree with the terms above * Yes Treatment Engagement Regular attendance at scheduled appointments is likely to lead to improved outcomes and progress in achieving therapy goals. I understand the following: • Cancelling/rescheduling three after hours or first appointments of the day within six months will lead to future bookings offered at alternative times; • Regular cancellations will decrease the opportunity for treatment goals to be achieved. I agree with the terms above * Yes Complaints and Feedback If you do not feel comfortable raising your complaint/feedback with your clinician, you can make a formal complaint to the Talking Works' Complaints Officer. o Complaints Officer: Julio Del Cid o Contact Number: 0424 137 038 o Email Address: admin@augeoyou.com I agree with the terms above * Yes Confidentiality • I understand that my file will be kept securely for a minimum of seven years after I finish with Talking Works or until my child is 25 years old. The file will be kept longer if legally required. • I acknowledge that limits of confidentiality have been explained to me - information is only disclosed under the following circumstances: o with the consent of the client or the client’s parent/guardian if the client is a child; o where there is a legal obligation to do so; o if there is an immediate & specified risk or harm that can be averted only by disclosing information; o in the course of supervision or professional training. I agree with the terms above * Yes Please state your full name * We are Connected to
