This E Disclosure and Consent is provided in compliance with the Electronic Signatures in Global and National Commerce Act, 15 USC §7001, et seq. (“E-SIGN Act”) and the Uniform Electronic Transactions Act, as adopted by the various states.
As used in this E Disclosure and Consent, the words “You” and “Your” refer to the particular person entering into or agreeing to the agreements between You and Early Autism Services, LLC (“EAS”) that are set forth on the EAS website (the “Website”) including, without limitation, the use of electronic signatures and the use and storage of “electronic records” as defined in the E-SIGN Act.
This E Disclosure and Consent describes how EAS delivers communications to You electronically. EAS may amend this policy at any time by posting a revised version on the Website. The revised version will be effective when posted by EAS. If the revised version includes a substantial change, EAS will provide You with thirty (30) days prior notice by posting a notice of the change on the Website.
Electronic Delivery of Communications
By entering into and accepting the agreements on the following pages of the Website, You agree and consent to receive electronically all communications, agreements, notices, documents and disclosures relating to such agreements and Your use of the Website (collectively, “Communications”). Communications include agreements and policies You agree to, including updates to these agreements or policies; annual disclosures; transaction receipts or confirmations; statements and transaction history; and any other transaction information or other information related to such agreements, policies, updates or the Website.
EAS will provide Communications to You by posting them on the Website and/or by emailing them to You at the primary email address designated by You.
Hardware and Software Requirements
In order to access and retain electronic Communications, You will need the following computer hardware and software: a computer with an Internet connection; current “web browser” that includes 128-bit encryption with cookies enabled; a current version of Adobe Acrobat Reader to open documents in pdf format; a valid email address (the primary email address designated by You); and sufficient storage space to save past Communications or an installed printer to print them.
EAS will notify You if there are any material changes to the hardware or software needed to receive electronic Communications from EAS. By giving Your consent, You are confirming that You have access to the necessary equipment and are able to receive, open, and print or download a copy of any Communications for Your records. You may print or save a copy of these Communications for Your records as they may not be accessible online at a later date.
How to Withdraw Your Consent
You have the right to withdraw Your consent at any time. To withdraw consent, You may send a written request (a) by regular mail to EAS at 5877 Livernois Ste #104 Troy, MI 48098, (b) by email to firstname.lastname@example.org, or (c) through the Website. If consent is withdrawn, EAS will mail any agreements in paper form to You by U.S. mail at the mailing address on file with EAS as Your primary mailing address along with instructions about how to return the signed paper agreements. You will be required to return the signed paper agreements within 10 days. EAS reserves the right to discontinue Your access to its Website and Web applications and/or terminate any and all agreements with You.
Requesting Paper Copies of Electronic Communications
If, after You consent to receive Communications electronically, You would like a paper copy of a Communication, EAS previously sent You, You may request a copy within one hundred eighty (180) days of the date EAS provided the Communication to You by contacting EAS as described above. EAS will send Your paper copy to You by U.S. mail. In order for EAS to send paper copies to You, You must have a current street address on file with EAS as Your primary mailing address. If You request paper copies, You understand and agree that EAS may charge You a Paper Communications Fee for each Communication at the current rate.
Updating Your Contact Information
You are responsible for keeping Your primary email address on file with EAS up to date so that EAS can communicate with You electronically. You understand and agree that if EAS sends You an electronic Communication but You do not receive it because Your primary email address on file is incorrect, out of date, blocked by Your Internet service provider, or You are otherwise unable to receive electronic Communications, EAS still will be deemed to have provided the Communication to You.
If You use a spam filter or other technology that blocks or re-routes emails from senders not listed in Your email address book, You must add EAS to Your email address book so that You will be able to receive the Communications EAS sends to You.
You can update Your primary email address or street address at any time by sending the updated information to EAS (a) by regular mail to Early Autism Services at 5877 Livernois Ste #104 Troy, MI 48098, (b) by email to email@example.com, or (c) through the Website. If Your email address becomes invalid such that electronic Communications sent to You by EAS are returned, EAS reserves the right to discontinue Your access to the Website, terminate any and all agreements with You, and/or deem any and all of Your accounts with EAS as “inactive”.
This Agreement contains important information about Early Autism Services, LLC’s (“EAS”) Services and business policies and procedures. Please read it carefully. Additional information regarding EAS’s Services and business policies and procedures may be found at EAS’s website: www.earlyautismservices.com
1.) Applied Behavior Analysis Services
Applied Behavior Analysis (“ABA”) Services consist of providing care to EAS’s patients, which includes, but is not limited to, individualized ABA programs; parent education; toilet training; sleep consultations; and feeding services. Each ABA program varies and is designed to fit each individualized Child’s needs. In addition, the Services provided by EAS calls for a very active effort on the parent(s)’ part. In order for the ABA programs to be most successful, the parent(s) must play an active role.
The first week of Services will require the parent to shadow either the Board Certified Behavior Analyst (“Consultant”) or Behavior Technician (“Therapist”), who is assigned to your Child. During this time, EAS can both decide if there is a mismatch between the assigned Consultant and/or therapist and your Child. In addition, during this time period, the Consultant and Therapist will become familiar with your Child’s needs and schedule. Data will be collected throughout the entire session. Data will be documented in the EAS data collection app. The collection of data is mandatory for the Services provided by EAS. If you have questions about EAS’s procedures in collecting data, please discuss with the Consultant and/or Therapist.
2.) ABA Therapy Sessions
ABA Therapy Sessions shall take place at the Child’s home. A parent and/or designated guardian shall be present at all times. If a parent and/or guardian is unable to be present for any length of time, please notify the Consultant and/or Therapist so the appropriate arrangements can be made. EAS and the parent will determine the length of the ABA Therapy Sessions in advance. The required minimum amount of time each ABA Therapy Session length is scheduled for is 2 hours. Any changes to the ABA Therapy Sessions shall be communicated immediately to the Consultant assigned to the Child’s care, which includes the session’s place of location, appointment time, or appointment length. Please note that the Therapists do not have the authority to make any changes to the ABA Therapy Session schedules.
3.) Rescheduling Therapy Sessions
When you need to reschedule any therapy sessions, please contact EAS Consultant and therapist at least one week in advance.
4.) Out of Pocket Costs for Cancelled Appointments
If you need to cancel a scheduled therapy session appointment, you will be responsible for the appointment fee unless you reschedule your appointment (as described earlier), or provide at least 24-hour advance notice. If you need to change the place of location or the appointment time of the scheduled therapy session, you must provide at least 24 hours advance notice. In addition, you will be charged for cancelled team meetings, unless you provide EAS one-week prior notice. By signing this Informed Consent Agreement, you have agreed to pay for any missed and/or late cancelled appointments that have not been rescheduled.
5.) Fees for Services; Court Related Services and Insurance
EAS’ fees for its Services are as follows (with exception of contracted rates with certain insurance companies):
Consultant $90.00 per hour;
Behavior Technician: $45 per hour;
Speech-Language Pathologist: $90 per half hour;
Occupational Therapist: $180 per hour.
Charges will be broken down into 15-minute intervals for periods of work of less than one hour. All fee arrangements will be made in advance and prior to the commencement of the Services depending upon the needs of your Child. If other services are required by EAS, which include, but are not limited to, writing reports, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries (for insurance purposes), fees for these services will discussed at the time they are requested.
b. Court Related Services.
In the event you become involved in legal proceedings (i.e. Dissolution of Marriage, Child Custody, etc.) that require EAS’s participation and if EAS’s fee is not paid by the attorneys, you will be charged for the time EAS spends responding to legal matters. Because of the difficulty of legal involvement, EAS charges $110.00 per hour for court related services. Court related services include talking with attorneys, preparing documents, depositions, travel time, preparation for testimony and court appearances. Charges for court related services are not covered by insurance.
c. Insurance Contracts and Discounted Fees.
If EAS has a contract with your insurance company, EAS will bill at the contracted rate. However, you will be responsible for any deductibles, co- payments or coinsurance charges.
d. Insurance Reimbursement and Managed Care.
If you are seeking reimbursement for services under your health insurance policy, you will be required to sign a consent, giving EAS permission to bill your insurance and release whatever information your insurance company requires to process the claims we submit. At a minimum, they will require a clinical diagnosis (see Appendix A and B for more details on insurance reimbursement and managed care and consent for EAS to bill primary and secondary insurance directly).
i. Information released to your Managed Health Care Plan "Managed Health Care" plans such as HMOs, POSs, and PPOs, typically require that they authorize mental health treatment (therapy) before providing reimbursement. They will require your clinical diagnosis, and often require additional clinical information such as treatment plans, updates on treatment progress, and even copies of your Clinical Record. To use your Managed Care Insurance you will have to sign a release giving your therapist permission to release this information to your Managed Care Company. ii. Managed Care Limits on Treatment Managed Care Plans may limit your mental health coverage to time limited short-term treatment approaches. In addition, insurance plans may limit coverage to a certain dollar amount or number of sessions per year. Please check your insurance carefully so you are clear on the number of sessions/coverage available.
ii. A payment plan does not qualify for the discount.
6.) Contacting EAS
If you have any questions or concerns about the quality of services, personnel (including Consultants or Therapists), the program, or of the agency in general during the time of your services, please to contact either Mareiko Au or Vincent Scarlata at firstname.lastname@example.org
7.) Professional Records
The laws and standards of EAS’s profession require that it keep clinical treatment records. You are entitled to receive a copy of your Child’s records if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your Child’s records, EAS recommends that you review them in a Consultant’s or Therapist’s presence so that the parties can discuss the contents. Patients will be charged an appropriate fee for any professional time spent in responding to information requests. You will be charged a fee of $1.00 a page for copying your Child’s clinical treatment records.
8.) Limits on Confidentiality
The law protects the privacy of all communications between a patient and a therapist. In most situations, your therapist can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA and/or Illinois law. However, in the following situations, no authorization is required (see Appendix C for details):
a. Sharing Information Among EAS Staff
Consultants and/or Therapists share clinical information as part of case consultation, coverage for vacation or illness, and quality assurance review. Also, administrative staff has access to records for billing purposes. Information is not shared when contraindicated. When records are transported, they are kept in a sealed envelope and not kept outside of the home or EAS’s office address for more than 24 hours.
b. Court orders, Governmental Requirements and Legal Proceedings
EAS may be ordered by a Court of competent jurisdiction or any other governmental agency to release confidential information. c. Legally Mandated Instances for Breaking Confidentiality Instances that legally mandated EAS for breaking confidentiality include: suspicion of child abuse; suspicion of elder abuse; imminent threat of harm to others; and imminent danger/serious risk of harm to self.
Using Your Managed Health Care Benefits
If you choose to utilize your Managed Health Care benefits you will have to sign a release of information form giving your consultant permission to release clinical information to your Managed Health Care Company. Early Autism Services, LLC will make every effort to release only the minimum information about your Child that is necessary for the purpose requested. This information will become part of the insurance company/managed mental health company files and will probably be stored in a computer. Though all insurance companies state that they keep such information confidential, we have no control over what they do with it once it is in their hands. Your consultant and/or therapist will provide you with a copy of any report submitted to your Managed Health Care plan, if you request it in writing.
Managed Care Limits on Treatment
Please keep in mind that insurance plans (particularly Managed Care plans) may limit your mental health coverage to time limited short-term treatment approaches designed to work out specific problems that interfere with a person's usual level of functioning. They may also limit coverage to a certain dollar amount or number of sessions per year. Regardless of what insurance you have you need to carefully check your benefits so you are clear on the number of sessions/coverage available and any procedures necessary for having this coverage authorized. Please keep in mind that certain services, such as educational testing, may not be covered by your insurance. You may feel that your Child may need more services than your insurance will cover (i.e., wish to continue therapy after insurance benefits end). If you are seeking more long- term services/therapy for your Child or have concerns that require more extensive therapy we will need to make arrangements for payment once your insurance benefits are no longer available, or if your managed care insurance declines to coverage such treatment. Remember, you always have the right to pay for my our services yourself to avoid the problems described above [unless prohibited by contract].
We may use legal means, including hiring a collection agency or going through small claims court to collect outstanding balances. These actions will require the disclosure of otherwise confidential information. In most collection situations the only information released regarding a patient's treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim].
By selecting that you "Agree" to the Informed Consent Agreement, the Parent hereby gives Early Autism Services, LLC (“EAS”) Consent and permission to bill the Parent’s insurance plan as designated below directly for EAS’s Services it provides to Parent’s Child. Parent shall exchange the information necessary to secure payment for EAS’s Services (including, but not limited to, the Child’s diagnosis, service dates, types of services, and any and all information needed to process the claims). Parent understands that if an insurance payment is made directly to him/her for EAS’s Services, the Parent is responsible for immediately sending payment to EAS. Parent shall notify EAS immediately of any changes made to his/her Child’s health insurance, including denial information.
1. Sharing information with Early Autism Services, LLC Staff.
Early Autism Services, LLC or EAS is a group practice with multiple therapists and administrative staff. Protected information will be shared with these individuals for clinical and administrative purposes, such as scheduling, billing, consultation, vacation/illness coverage and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All administrative staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. EAS staff routinely consults with one another about our work in order to improve the quality of our clinical services. We also share clinical information for coverage during illnesses and vacations. The only times we will not share information with a specific EAS therapist is when you specifically request this and this request is granted. Requests will be granted when you know a EAS therapist outside of the work setting, a EAS therapist is treating a spouse or family member and clinical practice dictates that the sharing of information might be problematic, or other specific circumstances agreed to by you and your therapist. For any such agreement to be valid the agreement must be noted in your clinical record.
2. Legal Mandates for Breaking Confidentiality.
There are some situations in which therapists are legally obligated to take actions, which they believe are necessary to attempt to protect others from harm even though such actions may reveal some information about a patient's treatment. These situations include: If therapist has reasonable cause to believe that a child under 18 known to therapist’s professional capacity may be an abused child or a neglected child, the law requires that therapist file a report with the local office of the Department of Children and Family Services. Once such a report is filed, therapist may be required to provide additional information. If therapist has reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months, the law requires that therapist file a report with the agency designated to receive such reports by the Department of Aging. Once such a report is filed, therapist may be required to provide additional information. If your Child has made a specific threat or violence against another or if therapist believes that your Child presents a clear, imminent risk of serious physical harm to another, therapist may be required disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking your Child’s hospitalization. If therapist believes that your Child presents a clear, imminent risk of serious physical or mental injury or death to himself/herself, therapist may be required to disclose information in order to take protective actions. These actions may include seeking your Child’s hospitalization or contacting family members or others who can assist in protecting your Child.
The following outlines Early Autism Services’ agency-wide policy for the involvement of any individual therapist or consultant in the planning and implementation of an Individualized Education Program (IEP). As is outlined below, the primary role of Early Autism Services in the IEP process is to ensure school readiness through in-home programming and to assist each family in securing an appropriate placement for their child.
B. PERSONNEL INVOLVEMENT:
The following outlines the role that each level of staff may take in the IEP process. This includes: a) behavioral technicians b) lead therapists and c) consultants (BCBA).
1. Behavioral Technicians are prohibited from attending an IEP meeting.
2. Consultants (BCBAs) may attend IEP meetings in the event that:
• Time has been expressly allotted during the IEP meeting for the consultant to provide insight.
• The IEP meeting does not interfere with any regularly scheduled sessions or team meetings. This includes sessions or meetings with the child in question and sessions or meetings with other children on the consultant’s caseload.
Please read the information below and confirm if you authorize Early Autism Services to communicate through email. If you authorize EAS to communicate via email, please provide your current email address at the end of this agreement.
I acknowledge that I have read and fully understand this consent form. I understand the risks of communicating by email, in particular the privacy risks explained in this form. I understand that Early Autism Services cannot guarantee the security and confidentiality of email communication. Early Autism Services will not be responsible for messages that are not received or delivered due to technical failure. I understand that I may also communicate with Early Autism Services by calling my assigned BCBA or during a scheduled appointment. I understand that phone calls or a scheduled appointment should be made for any urgent matter or communicating changes with my personal information. I understand that I may revoke this consent at any time by submitting a written notice at Early Autism Services, 5877 Livernois St. Suite 104, Troy, MI 48098. I understand Early Autism Services may stop using email as a means of communication upon written request.
It is the policy of Early Autism Services to afford Equal Employment Opportunities regardless of race, color, national origin, gender, age, marital status, religion, disability, sexual orientation, pregnancy, genetic conditions or predispositions, or certain military and veteran status. Further, all applicable laws relating to disability discrimination will be strictly followed. This policy of Equal Employment applies to all aspects of the employment relationship.
I/we agree not to solicit or employ any employee or independent contractor of EAS, including Consultants or Therapists, in any manner including, but not limited to:
• as an employee, consultant, or through a third party, other than general advertisement, without prior written approval by EAS during the term of this agreement and for at least two (2) years after the expiration, termination or conclusion of this agreement.
• Unless otherwise agreed to by the Parties, in the event that I/we violate this section, I/we agree to pay EAS a fee of fifty percent (50%) of the gross annual salary paid by EAS to such employee or individual contractor, including Consultants or Therapist. Such fee shall be paid by me/us upon hiring of such employee or independent contractor, including Consultants or Therapists
“Information,” as the term is used in this policy, includes without limitation any information owned or used by Early Autism Services, such as:
• Any company client’s parent or client lists.
• Any company database information, including addresses and telephone numbers.
• Any information from Early Autism Services client’s parent personnel files, including client’s parent addresses, telephone numbers, employment status and wage history.
• Any photographs, videotapes and sound clips of any Early Autism Services client’s parent or client.
Only those client’s parents who are authorized by Early Autism Services’ board of directors or executive team, or whose association permits them to do so, may speak on behalf of Early Autism Services. Notwithstanding the foregoing, specific permission from the Early Autism Services’ board of directors or executive team will be required before any Early Autism Services client’s parent may disseminate confidential Early Autism Services information. No client’s parent may knowingly dispense such information to any outside party unless authorization has been granted. This could include other client’s parents who do not have the right to know such information. Any breach will be considered a violation of Early Autism Services policy concerning confidentiality, and it may constitute a violation of state or federal law.
Monitoring of Network Communications
Early Autism Services reserves the right to monitor at any time any communications that use Early Autism Services networks in any way, including data, voice mail, telephone logs, Internet use and network traffic, to determine proper use. Early Autism Services will review network communications activity and will analyze use patterns. Early Autism Services may choose to publish these data to ensure that company resources in these areas are being used according to this policy. No client’s parent may knowingly disable any network software or system identified as a monitoring tool.
I/we have read and understood the materials included in the Consent Agreement as it relates to the provision of EAS's Services as authorized for my child. I/we agree to maintain confidentiality for all business policies, procedures, techniques, trade secrets, other knowledge or processes developed by EAS. I/we understand that all program materials are prepared solely for my/our use and cannot be copied, disseminated, published or shared with a third party without the approval of EAS. I/we understand that all program materials must be returned to EAS upon termination of this agreement.
PLEASE SELECT BELOW TO CONFIRM THAT YOU HAVE READ EARLY AUTISM SERVICES, LLC’S INFORMED CONSENT AGREEMENT, ALONG WITH APPENDICES A THROUGH H, THAT YOU ARE MAKING AN INFORMED CHOICE TO CONSENT YOUR CHILD TO EARLY AUTISM SERVICES, LLC’S SERVICES/ THERAPY, AND THAT, WITH INTENT TO BE BOUND, YOU AGREE TO ABIDE BY THE TERMS OF THE INFORMED CONSENT AGREEMENT, AND THE TERMS OF ALL OF THE APPENDICES A THROUGH H SET FORTH ABOVE.
This Parent Consent Agreement hereinafter referred to as “Agreement” is entered into between Early Autism Services, LLC (“EAS”) and Payor Full Name (“Parent”) [Parent Name Provided Below] dated the [Date Provided Below].
This Parent Consent Agreement hereinafter referred to as “Agreement” is entered into between Early Autism Services, LLC (“EAS”) and Payor Full Name (“Parent”) Parent/Guardian First Name* Parent/Guardian Last Name* dated the Date* . Client, Child/Client First Name* Child/Client Last Name* (“Child”) has been authorized to receive intensive behavior modification services (“Services”) from EAS. In order to assure that your child and family receive prompt, professional and competent Services from EAS the following guidelines have been developed.
1. During the first week of providing Services, we request that you become available to “shadow” Consultant and/or Therapist until they become familiar with your child and his/her schedules as well as get an intimate knowledge on the nature of his/her behaviors.
2. Please monitor your Child’s Services for the first couple of weeks and inform EAS immediately should there be a mismatch between your child and the Consultant and/or Therapist assigned to work with him/her.
3. Data will be collected throughout the entirety of the session. Treatment notes will be written in 7 minute increments throughout the session within the EAS data colletion app. The collection and completion of treatment notes is mandatory for the provision of Services. An iPad that houses the EAS data collection app shall be provided by EAS. Additionally, the fit between a child’s therapeutic needs and the program’s services is determined on an individual case basis by both the parent/guardian and the consultant. EAS provides services exclusively to children and adolescents under the age of 18 and their families.
4. Please allow an area where we can keep the Program Book in your We require the Program Book for the collection of our data. Only the Consultant, Therapist, any other designated agent of EAS, and/or parent will have access to the Program Book.
5. The family has the responsibility to maintain a working space for EAS employees that is free of potential health hazards such as bed bugs, fleas, or rodents. If the home becomes infested, EAS staff will refrain from conduction sessions until resolved.
6. The Parent agrees to engage and participate in a family education program for the Child’s care, treatment, and needs.
7. The Consultant or Therapist shall only provide Services to the Child designated in this agreement.
8. The Child’s parent or an appointed guardian shall be present at all times Services are provided to the Child by EAS.
9. If the parent will be away for any reason for any length of time and the Parent has designated a guardian; another family member and/or authorized agent (“Responsible Party”) to be present during the time when the Child is receiving Services by EAS, EAS requests that you advise the Consultant or Therapist at least one week in advance, so the Consultant or Therapist can make the necessary arrangements. (Designated guardian must be at least 18 years of age.)
10. Video or audio recording of therapy sessions, team meetings, or in any other instance that involves personnel associated with EAS without the written consent of EAS and the representative of EAS being recorded is prohibited. Any recording must be done with the written consent of the individual therapist being recorded. Additionally, an authorized representative of EAS must also give written consent of any recording that takes place.
11. Representatives of EAS are prohibited from taking pictures, video, or audio recordings of a child or any other family. Additionally, EAS representatives are prohibited from posting any information to the Internet that pertains to a child’s ABA program. If you have a concern about the actions of any individual affiliated with EAS that pertain to this policy, please contact EAS immediately.
12. The parties understand that the Child's treatment and Services may change due to the Child's development and response to EAS shall discuss any additional treatment requirements and/or next level of Services with Parent prior to transitioning such treatment and Services to the Child.
13. Community outings will be limited to settings that do not require money (i.e. park, shopping mall, library, bookstore). When EAS takes the Child on a community outing as defined herein, the Parent and/or Responsible Party (as defined in Paragraph 9) shall be present. During the community outings, the Parent and/or Responsible Party are in charge and responsible for the Child’s well-being, care and are and to monitor the Child accordingly. Parent and/or Responsible Party hereby waives, releases, and discharges EAS, its owners, employees, and/or authorized agents from any and all liability, loss, cost, claim, damage, injury and/or cause of action of any kind arising out of the Child’s participation in a community outing. In addition, Parent and/or Responsible Party shall indemnify and hold harmless EAS, its owners, employees, and/ or authorized agents from any and all such liabilities or claims made as a result of the Child’s participation in the community outings.
14. Physical intervention by a therapist in the presence of aggressive behavior may be necessary at some point during a child’s program. The use of physical intervention is only considered when all other strategies have been exhausted. Furthermore, physical intervention or restraint will only be used if there is concern for the immediate safety of the child or the therapist. Please call your consultant, Mareiko Au, or Vincent Scarlata with any questions or concerns about EAS’s policy on physical intervention.
15. The Services not included in this Agreement are as follows:
• The Consultant and/or Therapist shall not, under any circumstances, drive the Child in his/her private vehicles;
• The Consultant and/or Therapist shall not administer medications to the Child.
• The Consultant and/or Therapist shall not, under any circumstances, accompany the family and the Child on vacations;
• The Consultant and/or Therapist is only responsible for the Child assigned to him/ her and may not be given other siblings and /or family members to supervise;
• No money shall exchange between the Consultant and/or Therapist and the Parent; and
• The Consultant and/or Therapist shall not act as a babysitter for your Child.
16. Under no circumstances will EAS support parents or the Consultant and/ or Therapist engaging in dual relationships that compromise the guidelines and integrity of EAS (i.e. parents will not promote and/or engage the Consultant and/or Therapist in personal relationships and/or professional opportunities outside of EAS services). Furthermore, at all times the parent(s) must respect boundaries of the Consultant and/ or Therapist. It is prohibited for EAS staff and client families to connect on social media platforms.
17. The Consultant arranges all schedules in coordination with parental input. At the onset of services should you require changes in the schedule, please notify the Consultant. The Therapist is not authorized to make any schedule changes.
18. EAS's owner is Benjamin Wessels. If you have any questions or concerns about the quality of services, personnel (including Consultants or Therapists), the program, or of the agency in general during the time of your services, please contact either Mareiko Au or Vincent Scarlata at email@example.com.
19. Upon termination of this Agreement, EAS shall advise Parent of the Child's prognosis and information concerning the Child's continuing care and EAS will make available all necessary documentation and treatment records for continuity and coordination of care with subsequent providers. At the request of a parent/ guardian, EAS will contact subsequent providers with relevant information to ensure continuity of care.
a. Billing Policy
Early Autism Services will bill patient responsibility amounts on a monthly billing cycle. Deductible, and co-insurance or co-pays, will be invoiced for services rendered. Billing will commence the month after services start and will continue to be billed until your out of pocket maximum has been met and Insurance is paying at 100%.
Monthly invoices will be sent no later than the 10th business day each month and will be calculated on the insurance benefits that we have previously discussed with you. If for any reason claims are not paid according to that schedule, we will immediately make corrections and either issue a new invoice with corrected new amount due, apply any overage to a future invoice or issue a refund.
Payment for Services shall be paid 30 days after receipt of invoice. Please note that you are responsible for the charges you incur from our services per the discussion explaining your insurance benefits. CEAS charges a $75.00 fee for checks returned due to insufficient funds. Payment for “other services” as defined in Section 5 of the parent agreement, will be discussed at the time these services are requested.
d. Secondary Policy Coverage
It is the responsibility of you the client, to inform Early Autism Services of any secondary insurance coverage. This includes but is not limited to any Medicaid or state assistance. If we are not informed of this coverage prior to the start of services it is possible that we will not be able to get back coverage, and you would be liable for any out of pocket expenses incurred.
e. Payment Plans
A Payment plan may be available to families if required. A payment plan must be discussed prior to services beginning, or prior to a new year of services for existing clients. If a payment plan is needed, please immediately reach out to a billing team representative.
Early Autism Services understands that paying for services requires a lot, and as such we are happy to offer a 10% discount for all clients who pay invoices in full and on time. On the last invoice of the year we will apply a 10% discount to the entire out of pocket maximum for the year. Further, if a client would like to pay their out of pocket up front, we will offer a 15% discount to the overall out of pocket maximum for the year (this must be discussed before services begin, or before the end of January for a new service year)
g. Financial Assistance
Early Autism Services does offer financial assistance to our families in need. Our financial assistance policy allows families to submit for a reduced rate and is assessed on a case by case basis. The policy is largely based on the Health and Human Services federal poverty guidelines, and although your family may make more than the guideline level, we do offer assistance to families that make above and beyond guideline levels as well. If you feel that the burden of your out of pocket may be too much for your family, please reach out to the billing team for the financial assistance form.
a. Late Fees
i. The first occurrence of a late payment will be forgiven if it is resolved swiftly and discussed with a billing representative.
ii. The second occurrence will result in a 5% late fee assessed on the overdue invoice.
iii. The third occurrence will result in a 10% late fee assessed on any and all outstanding invoices.
b. Balance Carryover
Early Autism Services understands that the financial burden of services is high, and as such we can and will discuss a balance carryover into a new service year. A balance carryover cannot exceed more than half of the annual out of pocket maximum, and there must be an agreed upon payment plan in place to catch up payments in the new calendar year. If these things are not in place and we are unable to reach you to discuss the payment plan, we will work on a transition out plan prior to the new year beginning.
If a family has not made a payment and has not spoken with a billing representative, we will exercise every avenue we have to try and discuss the Parent Contract Agreement invoice with you. This includes but is not limited to calling and emailing with the information provided at intake and having your clinician request that you get in contact with the billing team. If no contact is made and no payment is received 90 days after an invoice has been sent, we will begin to work on a transition of services plan. If no payment is made at that time, we will continue to work with you to collect owed amounts for 100 days, at which time we will send your invoices to collections.
PLEASE SELECT BELOW TO CONFIRM THAT YOU HAVE READ EARLY AUTISM SERVICES, LLC’S PARENT CONSENT AGREEMENT, ADDENDUM TO PAYMENT AND BILLING POLICY OF THE PARENT CONSENT AGREEMENT, AND LATE PAYMENT AND NON-PAYMENT POLICY, AND THAT, WITH INTENT TO BE BOUND, YOU AGREE TO ABIDE BY THE TERMS OF THE AFOREMENTIONED AGREEMENTS.
The purpose of this policy is to ensure that all property maintained by Early Autism Services is kept in the best possible working condition and to ensure proper use of such property and Early Autism Services networks.
“Property,” as the term is used in this policy, is defined as any piece of equipment, furnishing, vehicle, building or supply leased, owned, donated or otherwise in the custodial care of Early Autism Services or any person acting as its agent.
No Early Autism Services client’s parent should expect any privacy on Early Autism Services premises or when using Early Autism Services property or networks, except that which is required by law.
Note: Early Autism Services client’s parent(s) designated to care for such property is liable for cost of damages including stolen, lost or corrupted electronics.
This contract serves as an agreement between the client’s parent and EAS to make the necessary additional payment on the client’s parent’s bill for the cost of lost, stolen, corrupted and/or damaged item caused by the client's parent/guardian.
General Guidelines on the Use of Company Property
All Early Autism Services client’s parent(s) must maintain his or her home environment in an orderly fashion and follow all Early Autism Services rules to ensure its equipment’s proper use and maintenance. If an client’s parent’s misuse of Early Autism Services property damages the property, Early Autism Services reserves the right to require the client’s parent to pay all of the cost to repair or replace the property. The cost will be included on your bill.
Misappropriation of Early Autism Services property is grounds for company policy violation and possible criminal action. No client’s parent may use Early Autism Services property (including iPads, computers, laptops, pagers, telephones, cellphones, copiers, faxes, Internet services and printers) for personal use unless specific permission has been granted by the client’s parent’s Clinical Director. If such permission is granted, the client’s parent will be responsible for the care and return of the loaned property. Special care should be taken to identify any concerns regarding its condition before the property is removed or used by the client’s parent for personal use.
Other Options Available: For EAS client’s parents in possession of iPad Only: It is an option for the client’s parent with a designated iPad to purchase AppleCare on their own volition. If the client’s parent decides to purchase AppleCare, it will be at their own cost. EAS will not be responsible for the payment of the application. Client’s parent Statement of contract
Acknowledgement (Please read carefully) I acknowledge that while my child is a client of Company, I will take proper care of all company equipment that I am entrusted with. I further understand that upon termination of services, I will return all property of Company and that the property will be returned in proper working order. I understand I may be held financially responsible for lost, stolen and/or damaged EAS equipment or property. I understand that the cost will be billed to my account. I understand that the purchase of AppleCare is of my own choosing and EAS is not responsible for any payments. This agreement includes, but is not limited to, the following: (iPads, iPhones, laptops and other equipment). I understand that failure to return equipment will be considered theft and may lead to criminal prosecution by Company.
PLEASE SELECT BELOW TO CONFIRM THAT YOU HAVE READ EARLY AUTISM SERVICES, LLC’S POLICY CONCERNING USE OF EARLY AUTISM SERVICES’ PROPERTY AND AGREE TO ABIDE BY ITS TERMS.
To provide qualitative treatment at recommended treatment dosages, supervision and/or parent education is available through interactive video communications and/or electronic transmission of information. This platform will allow for a Board Certified Behavior Analyst (BCBA) to regularly supervise your child’s program to ensure your child is making meaningful progress and provide you with feedback as needed. In-person therapy will still be provided by a behavioral technician if supervision is being provided. In addition, this platform will allow a Speech-Language Pathologist or an Occupational Therapist to provide therapy remotely. Remote parent education can be provided even if in- person therapy has been temporarily suspended.
In accordance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), any of your child’s personally identifiable and medical information is deemed Protected Health Information (PHI) and subject to HIPAA Privacy Standards. Any video that is transmitted is encrypted to ensure compliance with these standards. Any video that takes place is streamed live for treatment purposes and not recorded and any electronic transmission of information is sent through secure platforms. PHI will not be disclosed unless permitted by law and any breaches will be disclosed to you immediately.
● I will have my questions or concerns answered quickly and consistently.
● A BCBA will routinely be able to monitor my child’s program and make modifications as needed
● I will have a significant role in my child’s program and contribute consistently to progress made.
● Connection issues may occur. To prepare for this potential risk, my consultant and I will develop a plan to avoid and fix these issues at the onset of using these services.
● Consultation over the internet may result in a breach of privacy. To mitigate this risk, my consultant will communicate solely through HIPAA-compliant encrypted software.
To participate in this service, it is important that you understand and agree to the following statements:
1. The consulting BCBA, SLP or OT will be at a different location from me. A technician or other provider may be present with me in the room.
2. The consulting BCBA (and technician, if receiving supervision), SLP or OT may transmit or share documents or details electronically that pertain to the client or program. These documents or details will be shared across a HIPAA-Compliant software.
3. I will be informed if any additional providers will be present other than the assigned technician and or BCBA, SLP or OT. I will give my verbal permission prior to the entry of additional personnel.
4. A record will be kept of each consultation in the form of data collection and session notes. The session will not be recorded unless clinically indicated and is approved by you in advance.
5. I understand that remote supervision requires the use of high-speed internet, a wired video camera and electronic equipment that allows access to a web browser. If I do not have access to this, EAS will provide these materials for me. I agree to the safe-keeping of these materials and understand that I may be liabile for misuse or damage to said equipment.
Consent to receive ABA services during the COVID-19 pandemic:
This document outlines the requirements to remain eligible for services from EAS during the COVID-19 pandemic and outlines the potential risks to continuing services.
In the interest of staff and client safety, it is our expectation that you:
• Provide EAS Staff with regular accurate information about the status of being exposed to someone with COVID-19 symptoms (fever, cough, shortness of breath).
• Provide EAS staff with daily accurate information about the status of all members of the household in regards to showing any signs of COVID-19 as outlined by the CDC (fever, cough, shortness of breath).
• Take a daily temperature of everyone in the household and immediately notify EAS staff if someone has a temperature of 100.4 or higher
In addition, we ask that you agree to the following in line with CDC guidelines:
• All members of the household will refrain from public gatherings (anyone that still has to work should remain isolated from staff while rendering services in the home) and will refrain from having visitors to the home
• All members of the household agree to wash hands frequently, to include after sneezing, coughing, blowing nose, touching face, or consuming food or drink.
• If services are being rendered in the home, the space in which the client and clinician will be using must be thoroughly sanitized with disinfectants before and after each session, to include the restroom that the technician will be using.
The CDC has published the following guidelines:
• All members of the household agree to use social distancing while interacting while interacting with staff in the home.
• Staff will not bring toys and materials into the home.
Our staff has been made aware of all state and local shelter in place and social distancing requirements and we will continually keep them up to date on their obligations. We take these orders seriously and have taken them into consideration when outlining these requirements. You will be immediately notified should the status of our staff change and potential exposure information will be shared with you, while maintaining required confidentiality. We will work to reduce the number of staff to only see one to two client maximum. Please be advised that if they become compromised, we will no longer be able to offer services.
These events render us unable to continue services
• Not following any of the guidelines listed above
• Any member of the household coming into contact with a confirmed case of COVID-19
• Any member of the household showing signs of COVID-19 as outlined by the CDC (fever, cough, shortness of breath)
• Any member of the household that has a fever or 100.4 or higher
We are agreeing to continue to provide services to your child within the home setting until events render us unable to. This agreement does not guarantee services and does not override any orders that may come from the CDC, Governor, or other governing body. This agreement and the terms of this agreement may change at any time as this situation continues to evolve. In the event that we are no longer able to provide in person services, we will work with you to provide a suggested schedule, list of activities, strategies for teaching, and guidance on managing problem behavior. We will also work with you to set up video conferencing services to receive parent training services from our Board Certified Behavior Analyst if your insurance payor allows such services.
By signing this agreement, you are acknowledging that you have read and understand the expectations for your child to continue receiving services from EAS. You acknowledge that you are not being forced into this agreement and are signing of your own free will. By signing this agreement, you also acknowledge that there is inherent risk in continuing to receive services either in the home or clinic setting while COVID-19 is still actively spreading. Even with all the precautions we are putting into place, we cannot guarantee that there will not be a transmission of COVID-19 between your household and our staff. By signing this agreement, you acknowledge that you will hold harmless, EAS and all associated personnel for all aforementioned companies, for any and all harm that may come from continuing services during the COVID-19 pandemic.
Please provide contact information for any clinicians, insurance contacts, therapy providers, school personnel or other individuals your ABA consultant, Speech-Language Pathologist, or Occupational Therapist may share your child’s therapy progress with. Maintaining communication with physicians and other care providers can help create consistency of care for your child.
EAS personnel are required to maintain confidentiality regarding your child’s identity. Client files will be faxed to the primary care physician’s office to reduce risks associated with electronic communication.
Participation in consent is voluntary. You may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon the authorization. The authorization will expire six (6) months from the date of my signature, unless you revoke the authorization prior to that time. If there are any questions concerning consent to communication or confidentiality, please contact your assigned EAS BCBA or clinician.
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