This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and new client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operation. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires we obtain your signature acknowledging we have provided you with this information. Although these documents are long and sometimes complex, it is very important you read them carefully and you ask questions regarding the procedures. When signing this document, it will also represent an agreement between our clients/caregivers and IBSABA. You may revoke this agreement in writing at any time. That revocation will be binding unless we have taken action in reliance on it; if there are obligations imposed by your health insurer to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations.
Services and Discharge
IBSABA offers a full service ABA program. To determine the program needed for a client we initially complete an assessment to determine whether a client would benefit from our services. After it has been determined that our services are needed, a BCBA is appointed as the team leader and develops an individualized treatment plan based on the findings of the Assessment. The treatment plan includes general and specific goals with time frames for completion. The treatment plan also includes a scheduled reassessment generally six months from the time the treatment plan is developed. The treatment plan is then implemented by the BCBA who supervises Behavior Technicians on proper implantation of the treatment plan. As needed, the program is adjusted by a BCBA to accommodate the client’s progress. If the treatment plan is over challenging the plan will be modified with lower intensity goals. As the client advances through the program more challenging goals can be added to the plan. If after adjusting the treatment plan and following the updated plan we may determine our services is not the proper treatment for the client. If such a determination is made, we will follow our discharge and referral protocol. Once the client has attained the level of development similar to a typical developing child, the client will be put on a maintenance program until the BCBA determines services will no longer benefit the client. Being a sudden stop in services can be detrimental to the skills acquired, the discharge from services is done over a long period of time to achieve a smooth transition.
Except for rare emergencies, we will see you (or your child) at the time scheduled. We understand that circumstances (such as an illness or family emergency) may arise which necessitates the occasional cancellation of appointments. In these cases, in order to avoid any misunderstanding, we ask that you speak to our staff personally and give us at least 24- hour notice as possible to cancel or reschedule. This will allow us to offer your time to another person. You may be charged the standard hourly rate ($50) for appointments missed or cancelled with less than 24 hours advance notice. Please note that most insurance companies will not reimburse you for missed appointments and you remain responsible for these charges.
Services are best provided in an atmosphere of trust. Because trust is so important, all services are confidential except to the extent that you provide us with written authorization to release specified information to specific individuals or agencies.
IBSABA strives for excellence in its ABA program and an integral component to achieve that goal is family involvement. IBSABA requires caregivers carry over the therapy being implemented and record data for specific programs as outlined in the client treatment plan.
If the Client/Family refuses involvement in the treatment plan, as a last resort services may be
suspended or terminated based on the severity of the lack of involvement. IBSABA wants to help all clients we interact with but without the client/family involvement our treatment plans will not be as effective as possible.
To Protect the Client or Others from Harm
If we have reason to suspect that a client or other minor is being abused, we are required to report this (and any additional information upon request) to the appropriate state agency. If we believe that a client is threatening serious harm to him/herself or others, we are required to take protective actions, which could include notifying the police, and intended victim, a minor’s parents, or others who could provide protection, or seeking appropriate hospitalization.
Professional Consultations
Behavior Analysts routinely consult about cases with other professionals. In so doing, we make every effort to avoid revealing the identity of our clients, and any consulting professionals are also required to refrain from disclosing any information we reveal. We will inform clients of these consultations. If you want us to talk with or release specific information to other professionals with whom you are working, you will need to sign an authorization specifying what information can be released and with whom it can be shared.
Supervision Requirements for Private Pay Clients
BCBAs do not require supervision. Our BCBAs are provided with supervision by a BCBA however, our private pay clients are not financially responsible for this supervision. Programs implemented by Behavior Technicians require 1 hour of supervision per every 8 hours of direct instruction.
Miscellaneous Services
Additional Services are offered that may include, but not limited to, phone consultation, co-treatments, attendance of school meetings and IEPs, attendance of psychological evaluations, etc.
Cancellation and Late Fees
Cancellations with less than a 24 hour notification: $50 per appointment (Please refer to our cancellation policy for more details).
You should be aware that, pursuant to HIPAA, we keep clients’ Protected Health Information in one set of professional records. The Clinical Record includes information about reasons forseeking our professional services; the impact of any current or ongoing problems or concerns; assessment, consultative, or therapeutic goals; progress towards those goals, a medical, developmental, educational, and social history; treatment history; any treatment records that we receive from other providers; reports of any professional consultations; billing records; releases; and any reports that have been sent to anyone, including statements for your insurance carrier. Personal notes are taken during supervision sessions by the Behavior Technician. While the contents of personal notes vary from client to client, most are anecdotal notes related to progress and future goals, reference to conversations, and hypotheses of the professional. These Personal Notes are kept separate from the Clinical Record are not available to you and cannot be sent to anyone else, including the insurance company. Your signature below waives all rights, now and in the future, to accessing these records in any form under any circumstances. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in anyway for your refusal to provide it.
Patient’s Rights
HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints made about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you.
Contacting Us
Given their many professional commitments, our professionals are often not immediately available by telephone. If you need to leave a message, we will make every effort to return your call promptly (within 24-48 hours with the exception of holidays and weekends).
We will return your call between the hours of 9 am- 5 pm. In emergency or crisis situations, please contact your physician, or call 911 and/or go to the nearest hospital emergency room. Your signature(s) below indicates that you have read the information in this document and agree to be bound by its terms described above.
