PATIENT RIGHTS AND RESPONSIBILITIES

It is the policy of Kids Club ABA to preserve the rights of patients and to facilitate the staff’s awareness of these rights. Following is a list of patients’ rights and responsibilities:

Patient Rights

1. Patients will not be denied appropriate care on the basis of age, race, marital status, color, ethnicity, sex, sexual orientation, gender identity or expression, religion, physical or mental disability, socioeconomic status, or source of payment. Patients have the right to receive care that takes into consideration the psycho-social, spiritual, and cultural values of the patient

2. Staff: Patients have the right to know the identity and professional status of the individuals providing care to them. All staff members are required to introduce themselves and explain the role they play in the care of the patient.

3. Information regarding medical diagnosis: Patients have the right to receive information about their medical diagnosis, proposed course of treatment, procedures, and prospects for recovery. This information should be communicated in language that the patient can reasonably be expected to understand. If the provider withholds this information, he/she should record the reason for withholding in the patient’s record. When it is not medically appropriate to give this information to the patient, the information should be available to another authorized individual.

4. Safety: Patients have the right to expect reasonable safety in the performance of procedures and safety in the environment.

5. Refusal of treatment: Patients have the right to refuse treatment to the extent provided by law and to be informed of the medical consequences of that refusal. Patients who refuse care or treatment are responsible for the results of that decision. When refusal of treatment prevents Kids Club ABA from providing appropriate care in accordance with ethical and professional standards, the relationship with the patient may be terminated with reasonable notice.

6. Research, educational or experimental procedures: Patients have the right to information concerning research or experimental procedures proposed as a part of their care and have the right to refuse to participate in any such activity. Refusal to participate in any experimental procedures or research will not jeopardize or affect care in any way.

7. Request for service: Patients have the right to expect that Kids Club ABA will respond to a patient’s request for service whenever possible. Evaluation, service and/or referrals will be completed as indicated by the severity and urgency of the case.

8. Freedom from restraints: Patients have the right to be free from restraints except when necessary to protect the patient from injury to self or others. When providing restraint, the least amount of restraint necessary will be used. Restraints must be administered in accordance with applicable federal, state, and insurance regulations.

9. Access to the medical record: Patients have the right to read their medical record. Patients also have the right to read and/or obtain copies of their completed medical record upon request.

10. Privacy and Confidentiality of records: Patients have the right to privacy in treatment and in caring for their personal needs. Patients have the right to expect that communication and records regarding their care will be treated confidentially. Records will not be released except as authorized by patients or their legal representative.

11. Presenting a complaint: Patients and their family members or guardians have the right to present complaints to Kids Club ABA about any aspect of the patient’s care from Kids Club ABA.

12. Continuity of care: Patients have the right to expect reasonable continuity of care, including discharge-planning and discharge instructions. Patients are entitled to information concerning continuing health needs, alternatives for meeting those needs, and be involved in discharge planning. Patients, and when appropriate, their families, will be informed about the outcomes of care, including unanticipated outcomes.

13. Information regarding reimbursement charges: Patients have the right to receive an explanation of their reimbursement charge regardless of the source of payment. Patients will be notified when they are no longer eligible for insurance or when payment of their bill by others will end. Whenever possible, advance notice will be given.

14. Consent: Patients have the right to reasonably informed participation in decisions involving their health care. Patients should not be subjected to any procedure without their voluntary,
competent, consent or that of their legally authorized representative. Where medically significant alternatives for care or treatment exist, the patient shall be so informed.

TELEHEALTH SERVICES

This Informed Consent for Telehealth contains important information focusing on providing healthcare services using telehealth which may include telephonic or videoconferencing, Telehealth services may be an option for some of the ABA services provided to your child, depending on your child’s individual needs as well as insurance company requirements. Please read this carefully. When you sign this document, it will represent an agreement between you and Kids Club ABA. If in-person services are exclusively preferred or you wish to change to in- person services once telehealth has already been provided, you have the right to request that from Kids Club ABA. You will not be denied services if you do not consent to telehealth services.

Telehealth Assessment
In some jurisdictions, prior to an initial assessment being completed, the BCBA will conduct a telehealth assessment to determine if telehealth services would be beneficial and address the child’s needs. Only once telehealth services are deemed as appropriate will your child be properly assessed through telehealth by conducting an initial assessment.

Benefits and Risks of Telehealth
Telehealth refers to providing ABA services remotely using telecommunication technologies such as video conferencing or telephone. One of the benefits of telehealth is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care when the client and clinician are in different locations or are otherwise unable to continue to meet in person (e.g., during a public health emergency). It can also be more convenient and take less time than traditional face-to-face services. Although there are benefits to telehealth, there are some differences between in-person treatment and telehealth, as well as some risks. Possible risks to telehealth treatment may include:

Risks to confidentiality. If either the client or clinician are in a public setting during services, there is potential for others to overhear the session content. Kids Club ABA will take all reasonable steps to ensure privacy by training the staff in how to conduct telehealth sessions as well as ensuring that the platform being used is HIPAA compliant. It is important however to make sure to secure a private location for the session where others will not be present, and it is unlikely that services will be uninterrupted.

Issues related to technology. There are many ways in which technology issues may impact telehealth service delivery. For example, technology may malfunction during a session, or stored data could be accessed by unauthorized people or companies. In addition, telehealth services require both client and provider to have knowledge of how to connect to any devices or tools necessary for telehealth services. If the session is interrupted, disconnect from the session and attempt to reconnect.

Crisis management and intervention. Before engaging in telehealth, Kids Club ABA will identify which clients would require high levels of support or clients who demonstrate behaviors that may result in a crisis. They will not recommend them as appropriate candidates for telehealth services, and in-person services will be recommended instead. For clients who are recommended for telehealth services, an emergency response plan will be developed for potential incidents which will address crisis situations that may arise during the course of telehealth services. Clinicians will report any incident that occurs during telehealth services that require reporting to relevant city, state, and federal agencies, within the amount of time mandated by the laws of the relevant jurisdiction.

Insurance denials. While every attempt will be made to receive the appropriate level of care in the optimal service location for your child, insurance companies may deny or partially deny telehealth services which will ultimately depend on the individual medical necessity as well as insurance restrictions. Kids Club ABA can always seek in-person services in the event of the aforementioned situations.

Other risks related to telehealth. Depending on your place of residence, telehealth services may be delayed until it is determined that the practitioner available to service your child is properly licensed and able to provide telehealth services in that jurisdiction.

Concerns During Telehealth Services
If there is a malfunction with the electronic communication device or connectivity during a session, please attempt to restart your device and/or reconnect to the session. If you are unable to do so, contact the provider or Kids Club ABA to inform them of the issue. In case of an emergency, please contact emergency services immediately, and contact Kids Club ABA when it is safe to do so.

Electronic Communications

There may be specific criteria on which electronic communication devices are used to conduct telehealth services as well as which networks and/or electronic platforms will be accepted. Parents and/or caregivers are solely responsible for any cost incurred in obtaining any necessary equipment, accessories, or software to receive telehealth services.

In some jurisdictions, telehealth services via audio- only methods can only be provided for the following scenarios. Audio-visual telehealth is not available to the client due to lack of client equipment or connectivity, or if audio-only is the preference of the client. If the service can be effectively delivered without a visual or in-person component. Kids Club ABA will inform you of the option of audio-only telehealth services if it is applicable. However, although some jurisdictions may allow telephonic services, it will ultimately depend on the insurance company’s guidelines.

Notice of Privacy
Kids Club ABA has a legal and ethical responsibility to make their best efforts to protect all communications that are included in telehealth services. Given the nature of electronic communications technologies, there is no guarantee that communications will be kept confidential or that other people will not gain access to communications through illegal means. Kids Club ABA will attempt to use updated encryption methods, firewalls, and back-up systems to help keep information private, but there is a risk that electronic communications may be compromised, unsecured, or accessed by others. Parents and/or caregivers should also take reasonable caution to ensure the security of communications (e.g., only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth). The extent of confidentiality and the exceptions to confidentiality that were outlined in the informed consent all apply to telehealth as well. Please inform Kids Club ABA if you have any questions about exceptions to confidentiality.

Appropriateness of Telehealth
At any time, Kids Club ABA may decide to terminate ABA telehealth services if the client is engaging in behaviors or demonstrating deficiencies in skills that cannot be properly addressed in a remote setting. Kids Club ABA will contact parents and/or caregivers to determine if and when in-person services can be conducted.

Fees
The same fee schedule for in-person ABA services will apply for telehealth services as well. However, some insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your child’s insurance, HMO, third-party payor, or other managed care provider does not cover electronic therapy sessions, you will be solely responsible for all session fees incurred. It is best to contact your insurance company prior to engaging in telehealth sessions in order to determine whether these sessions will be covered. Kids Club ABA will assist you in obtaining this information and will inform you if there are any insurance restrictions in regard to telehealth. If there is a technological failure and the provider is unable to resume the connection, you will only be charged the actual session time.

Records
Telehealth sessions shall not be recorded in any way unless agreed to in writing by mutual consent and must be done for a particular reason. Kids Club ABA will maintain a record of the session in the same manner in which in-person sessions are kept in accordance with Kids Club ABA, policies that conform to federal, state and insurance regulations in accordance with HIPAA.

Kids Club ABA’S Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Kids Club ABA 289 S Culver St.
Lawrenceville, GA, 30046 Kids Club ABA
Moishe Bobker 404-458-0809
Info@kidsclubaba.com

EFFECTIVE DATE: 01/01/2024

Summary
This is a summary of how We may use and disclose your protected health information, rights, and choices when it comes to your information. We will explain these in more detail in the following pages.

Your Rights
You have the right to:

• Get a copy of all written or electronic protected health information.
• Correct your protected health information.
• Ask us to limit the information We share, in some cases.
• Get a list of those with whom We’ve shared your information.
• Request confidential communication.
• Get a copy of this privacy notice.
• Choose someone to act for you.
• File a complaint if you believe we have violated your privacy rights.

Your Choices
You have some choices about how We use and share information as We:

• Communicate with you.
• Tell family and friends about your condition.
• Provide mental health care.
• Market our services.

Our Uses and Disclosures
We may use and disclose your information as We:

• Treat you.
• Bill for services.
• Run our organization.
• Do research.
• Comply with the law.
• Respond to lawsuits and legal actions.

Purpose

Kids Club ABA (“We”) respect your privacy. We are also legally required to maintain the privacy of your protected health information (“PHI”) under the Health Insurance Portability and Accountability Act (“HIPAA”) and other federal and state laws.

As part of our commitment and legal compliance, we are providing you with this Notice of Privacy Practices (“Notice”). This Notice describes:

• Our legal duties and privacy practices regarding your PHI, including our duty to notify you following a data breach of your unsecured PHI.
• Our permitted uses and disclosures of your PHI.
• Your rights regarding your PHI.

Contact

If you have any questions about this Notice, please contact Moshe Bobker

PHI Defined

Your PHI:

• Is health information about you:
  • Which someone may use to identify you; and
  • Which We keep or transmit in electronic, oral, or written form.
• Includes information such as your:
  • Name;
  • Contact information;
  • Past, present, or future physical or mental health or medical conditions;
  • Payment for health care products or services; or
  • Prescriptions.

Scope

We create a record of the care and health services you receive to provide you with care and to comply with certain legal requirements. This Notice applies to all the PHI that We generate.

We and all of our employees and other workforce members follow the duties and privacy practices that this Notice describes as well as any changes once they take effect.

Changes to this Notice

We can change the terms of this Notice, and the changes will apply to all information We have about you. The new notice will be available on request, in our office, and on our website.

Data Breach Notification

We will promptly notify you if a data breach occurs that may have compromised the privacy or security of your PHI. We will notify you within the legally required time frame after We discover the breach. You will be notified in writing, by first-class mail, or We may email you if you have provided us with your current email address and you have previously agreed to receive notices electronically. In some circumstances, our business associates may provide the notification. In limited circumstances when We have insufficient or out-of-date contact information, we may provide notice in a legally acceptable alternative form.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

You have the right to:

• Get a copy of your PHI. You can ask to see or obtain an electronic or paper copy of the PHI that We maintain about you (right to request access). Some clarifications about your access rights:
  • We require you to make access requests in writing;
  • We charge a reasonable, cost-based fee for the costs of copying, mailing, or other supplies associated with your request;
  • you may request that We provide a copy of your PHI to a family member, another person, or a designated entity. We require that you submit these requests in writing with your signature, and clearly identify the designated person and where to send the PHI;
  • you may request that We direct a copy of your PHI to a third party of your choice on a standing, regular basis. We require that you submit these requests in writing;
  • if you request a copy of your PHI, We will generally decide to provide or deny access within 30 days, however, if We cannot act within 30 days, We will give you a reason for the delay in writing and when you can expect us to act on your request; and
  • We may deny your request for access in certain limited However, if We deny your access request, We will provide a written denial with the basis for our decision and explain your rights to appeal or file a complaint.
• Ask us to correct your medical record. You may ask us to correct or amend PHI that We maintain about you that you think is incorrect or inaccurate. For these requests:
  • you must submit requests in writing, specify the inaccurate or incorrect PHI, and provide a reason that supports your request;
  • We will generally decide to grant or deny your request within 60 days. If We cannot act within 60 days, We will give you a reason for the delay in writing and include when you can expect us to complete our decision, which will be no longer than an additional 30 days. We will only ask for an extension once in response to a request;
• We may deny your request for an amendment if you ask us to amend PHI that is not part of our record, that We did not create, that is not part of a designated record set, or that is accurate and complete;
• if We deny your request, We will tell you why in writing. You will have the right to submit a written statement disagreeing with the denial and, if you opt not to submit this statement, you may request that We provide your original request for amendment and the denial with any future disclosures of PHI subject to the However, We may prepare a written rebuttal to any individual’s statement of disagreement; and
• We will append the material created or submitted in accordance with this paragraph to your designated record.
• Ask us to limit what We use or share. You have the right to ask us to limit what We use or share about your PHI (right to request restrictions). You can contact us and request us not to use or share certain PHI for treatment, payment, or operations, or with certain persons involved in your care. We require that you submit this request in writing. For these requests:
  • We are not required to agree;
  • We may say “no” if it would affect your care; but
  • We will agree not to disclose information to a health plan for purposes of payment or health care operations if the requested restriction concerns a health care item or service for which you or another person, other than the health plan, paid in full out- of-pocket, unless it is otherwise required by law.

• Get a list of those with whom We’ve shared your PHI. You have the right to request an accounting of certain PHI disclosures that We have made. For these requests:
  • We will respond no later than 60 days after receiving the request. We may ask for an additional 30 days during this 60-day period, but if We do, We will only do it once, provide a written statement of why, and indicate the date by which We intend to send the response;
  • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures, such as any you asked us to make; and
  • We will provide one accounting a year for free, but will charge a reasonable, cost- based fee if you ask for another one within 12 months. We will notify you about the costs in advance and you may choose to withdraw or modify your request at that time.

• Choose someone to act for If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI. We will confirm the person has this authority and can act for you before We take any action.
• Request confidential communications. You have the right to request that We communicate with you about health matters in a certain way or at a certain location. For example, you can ask that We only contact you at work or at a specific For these requests:
  • We will not ask for the reason;
  • you must specify how or where you wish to be contacted; and
  • We will accommodate reasonable requests.
• Make a complaint. You have the right to complain if you feel we have violated your rights. We will not retaliate against you for filing a complaint. You may either file a complaint:
  • directly with us by contacting Moshe Bobker. All complaints must be submitted in writing; or the Office for Civil Rights at the US Department of Health and Human Services. Send a letter to 200 Independence Avenue, W., Room 509F HHH Bldg., Washington, D.C. 20201; call 1-800-368-1019 (voice) or TDD: 800-537-7697; or visit www.hhs.gov/ocr/privacy/hipaa/complaints/.

Your Choices

For certain health information, you can tell us your choices about what We share. If you have a clear preference for how We share your information in the situations described below, please contact us and We will make reasonable efforts to follow your instructions.

In these cases, you have both the right and choice to tell us whether to:

• Share information with your family, close friends, or others involved in your care.
• Share information in a disaster relief situation.
• Exclude your information.

If you are not able to tell us your preference, for example if you are unconscious, We may share your information if We believe it is in your best interest, according to our best judgment. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, we will not share your information unless you give us your written permission:

• Most sharing of a mental health care professional’s notes (psychotherapy notes).
• Marketing purposes.
• Selling or otherwise receiving compensation for disclosing your PHI.
• Certain research activities.
• Other uses and disclosures not described in this Notice.

You may revoke your authorization at any time, but it will not affect information that We already used and disclosed.

Uses and Disclosures of Your PHI

The law permits or requires us to use or disclose your PHI for various reasons, which We explain in this Notice. We have included some examples, but We have not listed every permissible use or disclosure. When using or disclosing PHI or requesting your PHI from another source, We will make reasonable efforts to limit our use, disclosure, or request about your PHI to the minimum We need to accomplish our intended purpose.

Uses and Disclosures for Treatment, Payment, or Health Care Operations

• Treatment. We may use or disclose your PHI and share it with other professionals who are treating you, including doctors, nurses, technicians, medical students, or hospital personnel involved in your care. For example, we might disclose information about your overall health condition to physicians who are treating you for a specific injury or condition.
• Billing and payment. We may use and disclose your PHI to bill and get payment from health plans or For example, we share your PHI with your health insurance plan so it will pay for the services you receive.
• Running our We may use and disclose your PHI to run our practice, improve your care, and contact you when necessary. For example, we may use your PHI to manage the services and treatment you receive or to monitor the quality of our health care services.

Other Uses and Disclosures

We may share your information in other ways, usually for public health or research purposes or to contribute to the public good. For more information on permitted uses and disclosures, see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. For example, these other uses and disclosures may involve:

• • Our business We may use and disclose your PHI to outside persons or entities that perform services on our behalf, such as auditing, legal, or transcription (Business Associates). The law requires our business associates and their subcontractors to protect your PHI in the same way We do. We also contractually require these parties to use and disclose your PHI only as permitted and to appropriately safeguard your PHI.
  • Health information exchanges. We may participate in health information exchanges, which support electronic information sharing among members for treatment, payment, and health care operations purposes.
  • Complying with the law. We will share your PHI if the Department of Health and Human Services requires it when investigating our compliance with privacy laws.
  • Helping with public health and safety We may share your PHI to:
    • report injuries, births, and deaths;
    • prevent disease;
    • report adverse reactions to medications or medical device product defects;
    • report suspected child neglect or abuse, or domestic violence; or
    • avert a serious threat to public health or safety.
  • Responding to legal We may share your PHI to respond to:
    • a court or administrative order or subpoena;
    • discovery request; or
    • another lawful process.
  • Research, We may share your PHI for some types of health research that do not require your authorization, such as if an institutional review board has waived the written authorization requirement.
  • Working with medical examiners or funeral directors. We may share PHI with coroners, medical examiners, or funeral directors when an individual dies.
  • Responding to organ and tissue donation We may share your PHI to arrange an authorized organ or tissue donation from you or a transplant for you.
  • Addressing workers’ compensation, law enforcement, or other government requests.
    We may use and disclose your PHI for:

• workers’ compensation claims;
• health oversight activities by federal or state agencies;
• law enforcement purposes or with a law enforcement official; or
• specialized government functions, such as military and veterans’ activities, national security and intelligence, presidential protective services, or medical suitability.

HIPAA Notice of Privacy Practices Acknowledgment Form

I acknowledge that I have received the HIPAA Notice of Privacy Practices from Kids Club ABA and that I have been provided an opportunity to review it. I understand that:

• I have certain rights to privacy regarding my protected health information.
• Kids Club ABA can and will use my health information for purposes of my treatment, payment for treatment, and health care operations.
• The Notice explains in more detail how Kids Club ABA may use and share my protected health information for other purposes.
• I have the rights regarding my protected health information listed in the Notice.
• Kids Club ABA has the right to change the Notice from time to time and I can obtain a current copy of the Notice by contacting the person listed in the Notice.

SIGNED AFFIRMATION OF COMPANY POLICIES AND
PROCEDURES:

I have received, read, understand, and agree to all Kids Club ABA policies and procedures and agree to the terms and conditions provided to me including:

• Introduction to ABA Services

• Parent Compliance Policy to ABA Therapy

• ABA and Home Safety

• Emergency Procedures

• Code of Conduct

• Complaint Policy

INFORMED CONSENT FORM FOR ABA SERVICES

Services

Kids Club ABA provides Applied Behavior Analysis (ABA) services using a natural approach, focusing on the overall quality of life for each individual and their family. Our mission is to use evidence-based and developmentally sensitive practices to help clients reach their greatest potential. Through connecting with caregivers and other professionals in your child’s life, we develop a client-focused plan to work on all areas of need. Kids Club ABA continuously improves the quality of services and accommodates clients and staff in the best way possible. Our annual improvement report can be reviewed upon request. ABA therapy is regulated by laws, ethics, your rights as a client, and standard business practices. Before intervention can begin, your agreement to the business practices described herein is required.

Possible Risks Associated with Treatment

• Disruptions to daily routine that can occur because of therapeutic changes.
• Client’s rate of acquiring skills may not develop as anticipated and client may experience difficulty retaining skills once learned.
• Temporary escalation of behavior in other settings due to new responses to interventions used.
• Initial increases in the duration, frequency, and/or intensity of problem behaviors.
• Development of other behaviors as a response to ABA treatment procedures

Although treatment begins with the hope of behavior improvement and positive outcomes, there is no guarantee that this will occur.

Potential Benefits Associated with Treatment

Multiple studies across the past half century have contributed to the current understanding of the benefits of Applied Behavior Analysis, including:

• Improvements in communication, social relationships, play, and functional skills.
• Increased participation in family and community activities.
• Improvements in “school readiness”.
• Significant improvements (socially valid improvements) in learning, reasoning, and adaptability to change.
• Studies have demonstrated that there is no age or diagnosis for which ABA services no longer have potential benefit, however it is well established that ABA treatment is mostimpactful for young children (ages 1-4 years), and when delivered intensively (25-40 hours a week). Individuals who receive intensive ABA treatment make larger improvements across more skill areas than do individuals who participate in other (non ABA) interventions.

Treatment Termination/Discharge

If at any time during the course of your treatment it is determined that services cannot continue, a discharge or transition report will be provided. Ideally, services end when treatment plan goals have been achieved. Additional conditions of termination/discharge can include:

• Parent request to terminate ABA services in which Kids Club ABA will provide a 30-day discharge period
• Failure to attend scheduled services for 45 consecutive days without any notification. Prior to discharge, the Kids Club ABA will make at least three attempts to make contact regarding the attendance procedure to discuss ways to facilitate attendance in the future, and the potential discharge for lack of attendance.
• Failure to comply with the predetermined schedule on a consistent basis and adhere to the Kids Club ABA policies and procedures.
• If a client’s individual treatment plan and goals have been met (e.g., the individual has achieved adequate behavioral stabilization congruent with age-appropriate development) and less-intensive treatment modes are appropriate, services are no longer clinically beneficial and ethical conduct standards require a termination of treatment.
• ABA Treatment is making symptoms persistently worse.
• The individual is not making progress toward treatment goals, as demonstrated by the absence of meaningful and measurable progress or stabilization of challenging behavior without any reasonable progress after multiple authorization periods.
• Other situations that warrant termination may include: drug abuse, disclosing illegal intentions or actions, inappropriate behavior during services, or another barrier to treatment that may warrant termination of services.

By Signing You:

• Acknowledge that therapy can involve potential physical, emotional, and mental risks, including but not limited to the potential for property damage, personal injury, and emotional duress.
• Understand and agree to the use of de-escalation and physical management techniques. Additionally, you hereby authorize Kids Club ABA to utilize techniques should your child engage in behaviors that cannot be safely managed in any other less intrusive manner.
• Acknowledge that proper implementation of Applied Behavior Analysis requires ongoing training and support from a Board-Certified Behavior Analyst, adherence to the treatment plan, and diligence in data collection.
• Acknowledge that you have read all of the information contained in this Informed Consent and that you have been fully informed about the nature of the treatment, risks involved and desired benefits.
• Confirm that you are legally competent and have the authority to provide consent for treatment.
• Voluntarily agree to receive treatment using Applied Behavior Analysis methods and that you may discontinue services, in writing, at any time.

FINANCIAL NOTICE

Insurance Coverage Details and Changes

Since ABA services are a mental health treatment funded by my insurance carrier, all specific ABA eligibility and coverage is determined by them. I understand that I am responsible for any copays or deductibles that are incurred based on my insurance policy. Payment is due in full at the time of service or upon receipt of a monthly bill from Kids Club ABA.

It is my responsibility to inform Kids Club ABA of any changes to my insurance policy so they can inform me of any changes as they occur. If my child has both a primary and secondary insurance policy, Kids Club ABA will attempt to bill both insurance carriers. I am responsible for any residual costs.

Incurred Fees

I understand that any charges not covered by my child’s insurance, as well any charges incurred by my delay in informing/not informing Kids Club ABA of changes to the insurance policy, are my responsibility. I further acknowledge that if I were to choose to pay privately, I am responsible for any services Kids Club ABA deems necessary for the treatment of my child.

Kids Club ABA agrees to bill all clients in a timely manner and keep a running account of payment owed. Failure to make payments two months in a row without an amendment to this agreement may result in termination of services.

Financial Assistance:

In the case of financial hardship, Kids Club ABA agrees to develop a payment plan to ease the financial burden. I understand and agree to pay Kids Club ABA a set cost per month until my entire bill is satisfied. Cost will be calculated based on the insurance cost, current income and financial status. Termination of services does not void the outstanding amount and I understand that I will need to continue to make payments until the bill is paid in full.

WAIVER OF LIABILITY FORM

Adult Present During Sessions:

I understand that it is preferred that I or another legal guardian be at home or present during therapy hours; however due to work and therapy schedules this may not be possible. I give permission for the employees of Kids Club ABA to work with my child at home, or out in the community without my presence. I understand that I must assign another adult to be present during ABA sessions and be responsible for my child in my absence.

If I wish to relinquish this agreement for any particular reason, I understand that I must do so in writing before the proposed therapy session is scheduled. I understand that the employees of Kids Club ABA are responsible only for the therapy sessions of the aforementioned child and not for any other child(ren) in the home. If an accident occurs while I or a legal guardian are not present during the session, I release Kids Club ABA (and its employees) from any liability. I understand that I will be contacted immediately if an accident occurs.

Property Damage:

I understand that, given that my child may have behaviors or lack of awareness which can result in damage of items and/or property. Kids Club ABA’s providers are trained to mitigate behaviors and to remove any valuables from all areas when ABA sessions occur. If any significant damage to Kids Club ABA items or property occurs, I am responsible for all costs incurred in the repair or replacement of the items/property.

Transportation:

I understand that it is my responsibility to ensure that my child is brought to the location of ABA services, either by myself or a designated guardian.