2021 New Patient Intake Forms

1
Date* This field is required.
Date
Year
Month
Day
2
Child's Name* This field is required.
First Name
Middle Name
Last Name
3
Child's Sex* This field is required.
Male
Female
N/A
4
Child's Date of Birth* This field is required.
Month
Day
Year
5
Child's Diagnosis* This field is required.
Childs Diagnosis
Diagnosing Physician and year of diagnosis
6
Name of Child's Adult Legal Gaurdian* This field is required.
First Name
Middle Name
Last Name
7
Mothers Name
First Name
Last Name
Phone Number
8
Fathers Name
First Name
Last Name
Phone Number
9
Emergency Contact* This field is required.
First Name
Last Name
Phone Number
10
Parent E-mail
example@example.com
11
Caregiver Main Contact Phone Number* This field is required.
Area Code
Phone Number
12
Marital Status
Single
Married
Divorced
Legally separated
Widowed
13
Child Lives With: (List all individuals living in the home. Include sibling ages)* This field is required.
14
Address where in home services will take place* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
Is the child taking any medications, currently?* This field is required.
Yes
No
16
If yes, please list it herePlease list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma.
17
Does the child have any allergies?* This field is required.
Yes
No
18
If yes, please list it here* This field is required.Please list all allergies, If there are no allergies indicate N/A
19
What language/ languages are spoken in the home* This field is required.
Huge
Large
Normal
Small
Ok
Ok
20
List all pets in the home * This field is required.
21
School Information* This field is required.
School District
Name Of School
City and State of School
22
Insurance Information (if not applicable enter N/A)* This field is required.
Insurance Carrier
Member ID
Name of Insured
23
Primary Care Physician
PCP/ Pediatrician First Name
PCP/ Pediatrician Last Name
Phone Number
24
HIPAA HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT NOTICE OF PRIVACY PRACTICES:(SIGN BELOW) This notice describes how protected health information about a client may be used and disclosed and how the client can gain access to this information. Please review it carefully. Morning Star ABA Therapy understands that we collect private and/or potentially sensitive medical information about each client and/or the client’s family. We call this information "protected health information." This notice explains the client’s privacy rights and addresses how Morning Star ABA Therapy may use and disclose protected health information. Morning Star ABA Therapy does not use or disclose protected health information unless permitted or required to do so by law. Morning Star ABA Therapy must adhere to laws aimed at securing the privacy of the client’s protected health information. These laws are known as the Health Insurance Portability and Accountability Act (HIPAA) privacy rules. When we do use or disclose protected health information, we will make every reasonable effort to limit its use or the level of disclosure to the minimum we deem necessary to accomplish the intended purpose. Please note that the privacy provisions articulated in this notice do not apply to health information that does not identify the client or anyone else. For more information on Morning Star ABA Therapy privacy practices, or to receive another copy of this notice, please contact: Morning Star ABA Therapy Email: Info@MorningStarABATherapy.com Phone: 714-552-1317 Fax: 714-782-5611 Morning Star ABA Therapy is required by law to follow the terms set forth in this notice. We reserve the right to change this notice. If we make a change in our privacy policies or procedures, we will provide the client with a new privacy notice either by mail or in person. PROTECTED HEALTH INFORMATION Protected health information is information about the client that relates to a past, present, or future mental health condition, or treatment or payment for the treatment that can be used to identify the client. This includes any information, whether oral or recorded in any form, that is created or received by Morning Star ABA Therapy. This also includes electronic information and information in any other form or medium that could identify the client. Examples of information that can identify a client include, but are not limited to the following: • Clients Name• Telephone Number• Address• Date of Birth• Social Security Number• Diagnosis• Start and End date of services USES AND DISCLOSURES OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS 1. Treatment, Payment, and Health Care Operations The following section describes different ways that we use and disclose protected health information for treatment, payment, and health care operations. Not every possible use or disclosure will be noted, and there may be incidental disclosures that are a byproduct of one the listed uses and disclosures. The ways we use and disclose protected health information will fall within one of the categories. a. Treatment We may use a client’s protected health information to provide the client with services, and we may disclose this information to any and all Morning Star ABA Therapy staff involved with the client’s treatment. Treatment includes (a) activities performed by Morning Star ABA Therapy personnel in the course of providing service to the client or in coordinating or managing the client’s service with other service providers and (b) consultations with and between Morning Star ABA Therapy staff and other professionals involved in the client’s treatment b. Payment We may use and disclose the client’s protected health information so that we may bill and collect payment from the client, an insurance company, or another party for services that Morning Star ABA Therapy provides to the client. We may also inform the client’s health plan provider of treatment we intend to administer in order to obtain prior approval or to determine whether the client’s plan will pay for the treatment. c. Health Care Operations may use and disclose the client’s protected health information in order to maintain necessary administrative, education, quality assurance, and business functions. For example, we may use a client’s protected health information to evaluate the performance of our staff in providing treatment for the client. We may also use information about clients to help us evaluate what additional services to offer, how we can improve efficiency, or the effectiveness of certain treatments. Additionally, we may use protected health information for review, analysis, and other teaching and learning purposes. 2. Special Circumstances Treatment, payment, and health care operations further include the circumstances listed below. a. Appointment Reminders We may use and disclose the client’s protected health information to contact the client as a reminder that he/she may have an appointment for treatment or services. b. Treatment Information We may use and disclose the client’s protected health information to contact him/her about treatment information. c. Satisfaction Surveys We may use and disclose the client’s protected health information to contact him/her about Morning Star ABA Therapy satisfaction surveys. 3. Uses and Disclosures You Can Limit a. Morning Star ABA Therapy Client Directory Unless the client notifies us that he/she objects, we may include certain information about him/her in Morning Star ABA Therapy Client Directory in order to respond to inquiries and disseminate information more efficiently. This directory is accessed by Morning Star ABA Therapy staff who may or may not be involved in the client’s treatment. b. General Notification Unless the client notifies us that he/she objects, we may provide his/her protected health information to individuals such as the client’s family members, caregivers, and friends, who are involved in the client’s treatment or who help pay for the client’s treatment. We may do this if the client informs us that we have their consent to do so, or if the client knows we are sharing the client’s protected health information with these people and the client expresses no objection or makes no reasonably discernable attempt to prevent us from doing so. There may also be circumstances when we can assume, based on our professional judgment, that the client would not object to disclosure of his/her protected health information. Also, if the client is not able to approve or object to disclosures, we may make disclosures to a particular individual (such as a client’s family member or friend), that we feel are in the client’s best interests and that relate to that person’s involvement in the client’s care. Other Permitted Uses and Disclosures of Health Care Information We may use or disclose the client’s health information without the client’s permission in the following circumstances, subject to all applicable legal requirements and limitations: 1. Required By Law Morning Star ABA Therapy must make any disclosures required by federal, state, or local law. These may include, but are not limited to, disclosures pertaining to: the reporting of abuse or neglect; court orders, subpoenas, warrants, or other lawful processes; identification/location of a suspect, fugitive, witness, missing person, or crime victim; crime on our work premises; or a serious, imminent threat. Employees of Morning Star ABA Therapy are designated as Mandated Reporters. 2. Public Health Risks We may make disclosures for public health reasons in order to prevent or control disease, injury, or disability; or to report births, deaths, disease or condition, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products. 3. Health Oversight Activities We may disclose protected health information to agencies authorized to receive reports for health oversight activities (e.g., Department of Health and Human Services, Office of the Attorney General) for audits, investigations, inspections, licensing purposes, or as necessary for certain government agencies to monitor the health care system, government programs, and compliance with civil rights laws. 4. Lawsuits, Disputes, or Other Legal Proceedings We may make disclosures in response to a subpoena or court or administrative order, if the client is involved in a lawsuit or a dispute, or in response to a court order, subpoena, warrant, summons or similar process, or if requested to do so by law enforcement. 5. Coroners, Medical Examiners, Funeral Directors, and Organ Donation We may disclose information to a coroner or medical examiner, (as necessary, for example to identify a deceased person or determine cause of death) or to a funeral director, as necessary to allow him/her to carry out his/her activities. 6. Research We may use or disclose protected information for research purposes under certain limited circumstances. Research projects are subject to approval by an institutional review board. Therefore, we will not use or disclose the client’s protected health information for research purposes until the particular research project, for which the client’s information may be used or disclosed, has been approved through the institutional review board. 7. Serious Threat to Health or Safety; Disaster Relief We may disclose information to appropriate individual(s)/organization(s) when necessary (a) to prevent a serious threat to the client’s health and safety or that of the public or another person, or (b) to notify the client’s family members or persons responsible for the client in the course of a disaster relief effort. We will disclose protected health information only to persons we believe to be able to lessen/prevent the threat and will limit disclosure to that which we deem necessary to lessen or prevent the threat. 8. Military and Veterans We must make disclosures as required by military command or other government authority for information about a member of the domestic or foreign armed forces. 9. National Security; Intelligence Activities; Protective Services We may disclose information to federal officials for intelligence, counterintelligence, and other national security activities authorized by law, including activities related to protection of the President, other authorized persons or foreign heads of state, or related to the conduct of special investigations. 10. Correctional Facilities We may make disclosures to a correctional facility (if the client is a ward) or a law enforcement official (if the client is in that person’s custody) as necessary (a) for the institution to provide the client with treatment; (b) to protect the client’s or others’ health and safety and the security of the correctional facility. When Written Authorization is Required Other than for the range of purposes previously identified in this notice, we will not use or disclose the client’s protected health information for any purpose unless the client provides us with specific written authorization to do so. If the client grants us authorization, the client can still withdraw this authorization at any time, though the authorization must be revoked in writing. In order to withdraw the authorization, the client must deliver, mail, email, or fax the revocation to Amanda Dissmore, at Morning Star ABA Therapy, email: Info@MorningStarABATherapy.com; fax: 657-845-4858. If the client revokes the authorization, we will discontinue the use or disclosure of the client’s protected health information to the extent that we relied on his/her authorization for the use/disclosure. However, we cannot take back or undo any use/disclosure made under the client’s grant of authorization prior to our receipt of the client’s written revocation of that authorization, and we must continue any use/disclosure that is necessary in keeping records of the client’s treatment. The Client’s Rights Regarding the Client’s Health Information The client has certain rights regarding his/her health information, which are listed below. In each of these cases, if the client wants to exercise his/her rights, the client must do so in writing by completing a form that the client can obtain from Morning Star ABA Therapy. In some cases, we may charge the client for the costs of providing materials to the client. The client can get information about how to exercise his/her rights and about any costs that we may charge for materials by contacting us at 714-852-0440 or Authorizations@MorningStarABATherapy.com 1. Right to Inspect and Copy With some exceptions, the client has the right to inspect and get a copy of the client’s protected health information that may be used to make decisions about the client’s care. We may deny the client’s request to inspect and/or copy information in certain limited circumstances, and, if we do this, the client may ask that the denial decision be reviewed. 2. Right to Amend The client has the right to amend his/her health information maintained by Morning Star ABA Therapy, or used by us to make decisions about the client. We will require that the client provide a reason for the request, and we may deny the request for an amendment if the request is not properly submitted, or if it asks us to amend information that (a) we did not create (unless the source of the information is no longer available to make the amendment), (b) is not part of the health information that we keep, (c) is of a type that the client would not be permitted to inspect and copy, or (d) is already accurate and complete. 3. Right to an Accounting of Disclosures The client has the right to request an accounting of disclosures. An accounting is a list of certain disclosures we made regarding the client’s protected health information. The list does not include all disclosures. For example, it does not include disclosure to the client, disclosure for treatment, payment, and health care operations purposes described above, or disclosure made with the client’s authorization as described above. 4. Right to Request Restrictions The client has the right to request a restriction or limitation on the health information we use or disclose about the client (a) for treatment, payment, or health care operations, or (b) to someone who is involved in the client’s care or the payment for it, such as a family member or friend. We are not required to agree to the client’s request. Any time Morning Star ABA Therapy agrees to a restriction, it must be in writing and signed by the Executive Director or his/her designee. 5. Right to Request Confidential Communications The client has the right to request that we communicate with the client about health matters in a certain method or at a certain place. For example, the client can ask that we only contact the client at home or by mail. 6. Right to a Paper Copy of This Notice The client has the right to a paper copy of this notice, whether or not the client may have previously agreed to receive that notice electronically. QUESTIONS AND/OR COMPLAINTS If the client has any questions about this notice, he/she should contact: Morning Star ABA Therapy Email: Info@MorningStarABATherapy.com Phone: 714-552-1317 Fax: 714-782-5611. If the client believes his/her privacy rights have been violated, the client may file a complaint with Morning Star ABA Therapy using the contact information provided above or with the Secretary of the Department of Health and Human Services. To file a complaint with the Secretary of the Department of Health and Human Services, call (877) 696-6775. If the client believes his/her privacy rights have been violated, contact: Office of Civil Rights, Medical Privacy Complaint Division U.S. Department of Health and Human Services 200 Independence Avenue, S.W. HHH Building, Room 509H Washington, D.C. 20201 Phone: (866) OCR-PRIV (627-7748) TTY: (886) 788-4989 Website: www.hhs.gov/ocr The client will not be penalized for filing a complaint and the client will continue to have the same access to Morning Star ABA Therapy services.* This field is required.
25
CLIENT SERVICES AGREEMENT AND INFORMED CONSENT FOR TREATMENT:(SIGN BELOW) The term of this Agreement shall begin on the above recorded Effective Date. The Responsible Party hereby consents for Applied Behavior Analysis (ABA) based behavioral health treatment to be rendered to above Client and agrees to abide by the terms set forth in this agreement and all policies and procedures set forth in the attached as well as any policies and procedures that may be communicated to Responsible Party from time to time. Subject to the terms of this Agreement and the attached Policies and Procedures MORNING STAR ABA THERAPY LLC hereby agrees to provide Client with ABA based behavioral health treatment. 1. Required Documentation and Further Action. Each party agrees to provide required diagnostic, insurance and/or personal information and to execute any documents required for the provisions of services. 2. Initial and Ongoing Assessment and Case Management. Prior to providing ABA certain Services to Client, an initial Functional Behavior Assessment (FBA) for the purpose of developing a treatment plan and establishing a baseline to measure Client’s progress is required. The initial assessment may include assessment of developmental, psychological, and intellectual functioning as well as adaptive behavior and linguistic/ verbal behavior skills. Unless otherwise agreed upon by the Responsible Party and MORNING STAR ABA THERAPY LLC, subsequent concurrent reviews/ progress reports of Client progress and functioning level will be conducted throughout the length of treatment. ABA programming requires remote (away from the client home) case management/ remote case supervision to be performed to analyze, compile and review data. Case management and re-assessment hours may also include research, consultation and review of clinical goals and programs. Program materials specific to each client will also be constructed remotely, these activities are billed to your insurance, per your insurance guidelines, and you may or may not be asked to sign for this remote time which is required to maintain your child’s program and goals. Remote (away from the client home) dates of service may also be reflected as a copay as applicable to your insurance plan. 3. Additional Services. Responsible Party hereby agrees to pay MORNING STAR ABA THERAPY LLC at the rates set forth in the then current fee schedule for any and all Services provided in addition to, or that exceed, the Services pre-authorized and/or authorized by Client’s Insurance Provider and/or any Services rendered that are not covered by the Insurance Provider (e.g. if coverage for Services is denied or dropped, in whole or in part, by the Insurance Provider for any reason) unless otherwise prohibited by the health care plan contract or applicable law. IF THE INSURANCE COMPANY YOU DESIGNATE IS INCORRECT OR IF NO COVERAGE EXISTS YOU WILL BE RESPONSIBLE FOR PAYMENT. 4.Insurance. When insurance coverage exists, and Responsible Party agrees in writing (by signing this service agreement), that MORNING STAR ABA THERAPY LLC will submit claims for Services to the Insurance Provider. Responsible Party hereby agrees to the pay MORNING STAR ABA THERAPY LLC for any deductible, co-payment, co-insurance and/or any other fees applicable. Responsible Party must provide accurate and current primary and secondary Insurance information. Responsible Party hereby authorizes MORNING STAR ABA THERAPY LLC to provide any and all Services pre-authorized and/or authorized. Responsible Party understands they are responsible for payment of all services rendered that are not covered by their insurance carrier unless otherwise prohibited by the health care plan contract or applicable law. Responsible Party shall notify MORNING STAR ABA THERAPY LLC of any change in Insurance Provider or health care plan within twenty-four (24) hours. 5. Initial Retainer for private pay. If coverage by an Insurance Provider lapses, is non-existent, undetermined, disputed or pending, MORNING STAR ABA THERAPY LLC requires pre-payment of fees prior to the commencement of Services. Any unused portion of the Initial Retainer will be applied towards subsequent Services. MORNING STAR ABA THERAPY LLC requires an ongoing retainer/pre- payment for private pay. If Responsible private pay Party does not wish to pay the Initial Retainer, services will be put on hold pending pre-authorization/authorization from an Insurance Provider. If Client Insurance coverage is dropped Responsible party agrees to pre-pay continued ABA services at the rates set forth in the then current fee schedule for any and all Services. 6. No-Show/Late Cancellation. If a scheduled appointment is canceled with less than 24-hours’ notice, or the Client is a No-Show to the scheduled session the Responsible Party agrees to pay MORNING STAR ABA THERAPY LLC for the entire amount/duration of services scheduled at the rates set forth in the then current fee schedule unless otherwise prohibited by the health care plan contract or applicable law. 7. Invoice Payment. MORNING STAR ABA THERAPY LLC will provide Responsible Party a monthly Invoice including fees for service incurred during the prior month. Payment in full is due within fourteen calendar days of the Invoice date. All fees are to be paid to MORNING STAR ABA THERAPY LLC by check, money order or credit card. Responsible Party agrees to provide a valid credit card number and authorization to charge any and all passed due fees to the credit card if the fees remain unpaid after fourteen calendar days from the Invoice Date. 8. Collections and Billing Disputes. If Responsible Party does not notify MORNING STAR ABA THERAPY LLC, in writing, of any objection to the information on any Invoice within thirty days of the Invoice date, we will assume the Responsible Party approves of the Services rendered and charged. Invoices that remain unpaid after thirty days of the Invoice date may be referred to a third party collection agency. The Responsible Party shall be responsible to pay MORNING STAR ABA THERAPY LLC all costs incurred in the course of collection. Past Due Invoices will accrue interest at the rate of seven percent or the maximum rate permitted by applicable law, whichever is less, beginning on the fifteenth calendar day following the Invoice date. 9. Conflict of Interest; Local Education Agency Services. If Client is receiving Services from a Local Education Agency ,public or private school in which MORNING STAR ABA THERAPY LLC is the Non-Public Agency Service Provider and Responsible Party seeks supplemental ABA Therapy from MORNING STAR ABA THERAPY LLC per this Agreement, Responsible Party is responsible to ensure Client’s Individualized Education Plan (IEP) provides Free Appropriate Public Education (FAPE) and agrees the Services provided pursuant to this Agreement are supplemental and non-related. 10. Interruption/Temporary Suspension of Services. Upon notice either party may place a hold on/temporarily suspend services for a specified period of time, not to exceed ninety days. Temporary suspension of services shall not result in termination of the Agreement. Upon resuming services pre-authorization or authorization of treatment may be required from the insurance plan. Authorization request times vary greatly between insurance plans and may further delay resumption of services. 11. Termination. Responsible Party may terminate Services at any time for any reason, or no reason. MORNING STAR ABA THERAPY LLC may terminate Services for any reason, or no reason, upon providing thirty days’ prior notice to Responsible Party or immediately for cause, as determined in MORNING STAR ABA THERAPY LLC discretion. 12. Indemnification. Responsible Party agrees to defend, indemnify and hold MORNING STAR ABA THERAPY LLC harmless from and against any and all third-party claims, demands, liability and/or expenses arising out of or in connection with the Services rendered to Client, other than claims arising solely from the intentional misconduct or gross negligence of MORNING STAR ABA THERAPY LLC or its personnel. 13. Risks and Informed Consent. ABA services are never guaranteed to alter behavior, although ABA is successfully utilized to decrease problem behaviors and increase pro-social behaviors and independence in other individuals this does not guarantee MORNING STAR ABA THERAPY LLC services will have the desired effect for Client. Services rendered may or may not create the desired behavioral change in Client. ABA treatment has risks which may include an increase in problem behaviors, of which may be the original behaviors of concern. In many cases, problem behaviors get worse before they get better; this is referred to as “extinction burst”. There is a possibility that problem behaviors may permanently increase in rate and or intensity and new problem behaviors may also emerge. By signing this agreement the caregiver acknowledges the risks associated with ABA treatment. It is agreed that fees for service are due regardless of the outcome of services. Risks of not starting ABA treatment include continuation of the problem behaviors and skill deficits of concern which may affect long term socialization, independence and behaviors. 14. Attorneys’ Fees and Costs. Should any mediation, litigation, arbitration or other dispute resolution proceeding be commenced between the Parties to enforce or interpret this Agreement or concerning this Agreement or the subject matter within or the rights and duties of the Parties in relation to each other, the Party prevailing in such Proceeding (whether at trial or on appeal) shall be entitled, in addition to such other relief as may be granted, to its costs and expenses of participation in such Proceeding, including without limitation a reasonable sum as and for its attorneys’ fees and costs in such Proceeding, which shall be determined by the court or other trier of fact in such Proceeding or in a separate action brought for that purpose. In interpreting this Agreement each section, heading, paragraph and caption shall not be considered a part of the Agreement or affect its interpretation and shall not limit or affect the meaning and its provisions shall not be interpreted in favor of or against either Party based on who prepared or drafted the Agreement or for any other reason. This Agreement shall be governed by and construed in accordance with the laws of the State of California. In the event of a dispute arising from the terms of this Agreement, the jurisdiction shall be in Orange County, California. 15. Entire Agreement of the Parties. This Agreement supersedes any and all agreements, either oral or written, between the Parties within with respect to the rendering of Services by MORNING STAR ABA THERAPY LLC and contains all of the agreements between the Parties with respect to the rendering of such Services. Each party to this Agreement acknowledges that no representations, inducements, promises, or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any other party, that are not embodied herein. Each party acknowledges that no other agreement or promise not contained in this Agreement shall be valid or binding. Any provision of this Agreement found to be void, invalid or unenforceable shall be severed and shall not affect the other provisions of this Agreement, and the Agreement shall be construed in all respects as if such invalid or unenforceable provisions were omitted. Any modification of this Agreement will be effective only if it is in writing signed by both parties. The waiver by any party to a breach of any provision of this Agreement must be in writing and signed by such party to be effective, and shall not operate or be construed as a waiver of any subsequent breach of this Agreement. BY SIGNING THIS AGREEMENT I/WE ACKNOWLEDGE THAT I/WE HAVE READ, UNDERSTOOD AND AGREED TO ALL OF ITS TERMS. I/WE SPECIFICALLY ACKNOWLEDGE AND UNDERSTAND THAT IF COVERAGE FOR SERVICES IS DENIED BY THE INSURANCE PROVIDER, I/WE ARE RESPONSIBLE FOR THE FULL PAYMENT FOR ALL SERVICES RENDERED. If the Client is a minor person under eighteen years of age or without legal capacity, Responsible Party hereby confirms they hold authority to sign this Agreement on behalf of the Client. This Agreement shall bind and inure to the benefit of the Parties, their successors and assigns.* This field is required.
26
AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION: I hereby give my written consent to Morning Star ABA Therapy to release medical information, including specifically, information about treatment verbally and via email correspondences, with the Following individuals* This field is required. (If you do not wish to release information to any individual type n/a in each box)
Title and Full Name of whom your child's protected health information may be released to
Specific documents and or information that may be released to the above individual/s
Contact Email for the above person/s whom your child's protected health information may be released to
CContact Phone Number for the above person/s whom your child's protected health information may be released to
27
AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION: Please be aware that because the funding of your child’s services may come from your regional center and/or school district, and/or insurance carrier, information regarding your child will be shared with them as a result of this relationship. Upon request, you have a right to receive a copy of this authorization. A photocopy is as valid as the original. MORNING STAR ABA THERAPY LLC respects and abides by all required privacy/confidentiality standards concerning client care and employs reasonable safeguards to protect against use and disclosure of protected health information. Nonetheless, by participating in therapy sessions and/or programs (e.g. in-clinic group therapy, in-school therapy, community-based outings/events, etc.), it is possible certain private/confidential information (e.g. client name, diagnosis, etc.), including specifically health information that may otherwise be protected from disclosure, may be exposed/disclosed, either implicitly or explicitly, to third-parties present in your home (e.g. other family members, friends, babysitter/ nanny, housekeeper, etc.), other clients, parents, guardians, conservators or other responsible parties, teachers, participants and/or members of the general public. By participating in individual or group therapy, in-school, community-based outings/events, etc certain private/confidential information (client name, diagnosis), including specifically health information that may otherwise be protected from disclosure will/may be exposed/disclosed, either implicitly or explicitly to other parents, guardians, conservators or other responsible parties, teachers, participants and/or members of the general public. Unless otherwise instructed in writing, MORNING STAR ABA THERAPY LLC staff will conduct therapy sessions and/or programs despite the presence of third-parties and you, on behalf of yourself and the client agree to absolve/discharge MORNING STAR ABA THERAPY LLC from any and all liability relating to or arising from any disclosure (incidental, limited or otherwise). Your signature below represents your understanding of the information given and agreement to these terms. * This field is required.
28
CONSENT FOR ABA SERVICES AT ADDITIONAL LOCATION: I (patient caregiver) hereby give my written consent to Morning Star ABA Therapy LLC to provide the full range of ABA services (Direct 1:1 Therapy, Assessment, Parent Consult and Supervision of Direct therapy) for my child at the school and/or center location described below. * This field is required.Please note this form is required if you desire to have services in any center or public location outside of the child's home. If you wish to release medical information to anyone at this location include their information in the previous Authorization for the use and disclosure of Protected Health Information form.(If you do not wish to hold services in any location other than your home type n/a in each box)
Name of location/s where I give consent for ABA services to be held
Contact full name at the location where I give consent for ABA services to be held
Address of the location where I give consent for ABA services to be held
Contact Phone Number at the location where I give consent for ABA services to be held
29
Telehealth Consent Form:

In response to the current COVID-19 pandemic and efforts to socially distance wherever possible certain insurance funding sources are now allowing immediate telehealth/ remote services for Direct 1:1 Therapy, Parent Consultation and Supervision.

Definition: Telehealth, telemedicine, and related terms generally refer to the exchange of medical information from one site to another through electronic communication to improve a patient’s health. Electronic communication will vary between insurance agencies, some allow phone calls while others require a face to face video component.

If you are receiving this notice you have the option of consenting to receiving “Synchronous interaction” telehealth services which means a real-time interaction between a patient and a health care provider located at a distant site. This applies to Direct 1:1 Therapy, Parent Consultation and Supervision/oversight of the direct therapy team and ABA programming. Restrictions may apply per your insurance plans guidelines and this benefit may need to be verified with your insurance plan before telehealth may begin.

If you wish to consent to telehealth remote services such as telephone and video conferencing option’s please do so by choosing Yes and signing and dating below. If you do not consent to telehealth services choose No and sign and date below.

Purpose and Benefit

The purpose of the tele-health consultation is to enable clients living in rural, underserved, and/or times of national emergencies (i.e., social distancing due to health crisis) to obtain access to specialists without the time, expense, or exposure of such conditions.

Confidentiality

Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the tele-health consultation. All existing confidentiality protections under federal and state of California law apply to information disclosed during this tele-health consultation. The consultation is conducted using HIPAA compliant video software. Under conditions of national emergencies (i.e., social distancing due public and community health crisis) regulations and policies provided by HIPAA may be relaxed or not enforced. Under such conditions, provider may use “popular” technology (e.g., facetime, Facebook, google hangouts, RingCentral, or skype etc) to conduct or perform telehealth consultation.

Risks and Consequences

The telehealth consultation will be similar to routine BCBA/ or Associate Supervisor supervision, except interactive video technology will allow you to communicate with the BCBA/Associate Supervisor at a distance, and will allow the BCBA/Associate Supervisor to observe the paraprofessional (e.g., RBT, ABAT, behavior technician) working with your son/daughter and provide feedback at a distance. The use of video technology to deliver behavioral healthcare and educational services is a new technology and may not be equivalent to direct client to provider contact. The risks to you and/or your child due to participating in telehealth include, but are not limited to, interruptions, unauthorized access by third parties, and technical difficulties.

Risks and Consequences of Direct Therapy via Telehealth

The use of video technology to deliver behavioral healthcare and educational services is a new technology and may not be equivalent to direct client to provider contact. The risks to you and/or your child due to participating in telehealth include, but are not limited to, interruptions, unauthorized access by third parties, and technical difficulties. Additional risks include physical barriers that do not allow staff to physically prompt the member, to reduce this barrier we ask that parents accompany their children during any direct therapy telehealth sessions and assist in physical prompting and guidance of the member per the Behavior Technicians guidance. If at any time the caregiver wishes to cease telehalth direct 1:1 services or if they dont believe it is beneficial they may imidiately terminate. Please contact scheduling with any concerns or any requests for termination of telehealth direct 1:1 therapy performed by the behavior technician. Scheduling contact:714-720-7733. You may also notify the supervisor assigned to your case.

Rights

You may withdraw consent for any telehealth session or consultation at any time without impact on your right to future care and treatment, or without risking withdrawal from program benefits to which you would otherwise be entitled.

We will ask you to specify which services you desire via telehealth before we schedule telehealth/virtual sessions. You can choose to only recieve Supervision and Parent Consultation via telehealth and to not receive Direct 1:1 therapy, or any mix of the 3 services or none.
30
Consent For Telehealth Services (Direct 1:1, Parent Consult, Supervision). Purpose and Benefit * This field is required.Do You Consent to receiving any telehealth service as described on the previous page?
Yes
No
31
Telehealth Services Informed Consent. Please sign below to acknowledge you read and understand the above Consent For Telehealth Services Form and the information contained within in regards to the definition, purpose, risks, consequences, benefits your rights and confidentiality. If you have any questions or concerns please contact the Director at 714-552-1317.* This field is required.Legal Guardian Signature
32
COVID-19 Waiver and Release of Liability Form: Morning Star ABA Therapy LLC.

Services: Behavioral Health Treatment (BHT) Services
I, ON BEHALF OF MYSELF AND MY DEPENDENTS, HEREBY ASSUME ALL OF THE RISKS OF REQUESTING THIS SERVICE, including by way of example and not limitation, any risks that may arise from contracting COVID-19 from my Service Provider, gross negligence, negligence or carelessness on the part of the Service Provider and releasing my Service Provider from any and all liability from any medical condition, viruses, of the Service Provider and contracting such viruses from the Service Provider. This Waiver and Release of Liability covers any negligence or gross negligence in relation to exposing me or my dependents to the COVID-19 virus from Service Provider while visiting my home.

I am responsible for determining whether I am physically and medically able to allow the Service Provider into my home and provide Services. I am responsible for determining whether a physical or medical examination should be undertaken before I or my dependents participate in the services being provided and I will abide by any determination, limitation, or recommendation that may be issued by my medical or health care provider. Before, during, and after the services, I am solely responsible for determining my and my dependent’s health and physical status and whether I or my dependents can or should discontinue my participation in the services, or take other actions, to protect my own, and my dependents, health or safety. Service Provider assumes no duty to me or my dependents to ensure my physical or medical ability to participate in the services, whether before, during, or after the services.

I acknowledge that this Waiver and Release of Liability Form will govern my actions and responsibilities at said services, activity or event.
In consideration of providing services to me and/or my dependents, I hereby take action for myself, dependents, my executors, administrators, heirs, next of kin, successors, and assigns as follows:

(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this event, THE FOLLOWING ENTITIES OR PERSONS: Service Provider and its directors, officers, employees, representatives, employee, and agents;

(B) I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this service, activity or event, whether caused by the negligence of release or otherwise. Me and my dependent’s participation in the services is voluntary.

I acknowledge that Service Provider and its directors, officers, employees, representatives, and agents are NOT responsible for the contamination, errors, omissions, acts, or failures to act of any party or entity conducting in providing the services.

I acknowledge that this activity, event or service may carry with it the potential for death, serious injury, and property loss.
The accident waiver and release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
33
COVID-19 Waiver and Release of Liability Form: Morning Star ABA Therapy LLC. * This field is required.Legal Guardian Signature
34
PAYMENT AGREEMENT: You are responsible for all co-payments, deductibles and coinsurance. It is your responsibility to understand your insurance benefit plan and to know if a written referral and/or pre-authorization is required for ABA services and what services are covered. You will be asked for your insurance card at the time of intake; this is your verification of your correct insurance and consent to bill them. IF THE INSURANCE COMPANY YOU DESIGNATE IS INCORRECT, YOU WILL BE RESPONSIBLE FOR PAYMENT AND TO SUBMIT ALL CHARGES TO THE CORRECT PLAN. Not all services are covered by every plan, any service determined not to be covered by your plan will be your responsibility. If Morning Star ABA does not participate in your insurance plan, payment in full is required from you. Copayments may be due for each date of service or service type, depending on your insurance plan. This includes treatment planning that is not face to face such as FBA/assessment writing, case management and progress report writing. Repeated failures to attend scheduled sessions or frequently arriving late to scheduled sessions may result in termination of services. Late cancellations and client No-shows will be charged a 35$ fee per cancellation, where applicable. A late cancellation/no show is any time caregivers cancel a scheduled appointment within the same day, or if the family is not present when staff arrive for a scheduled session. Third party costs are the responsibility of the caregiver. This includes costs associated withholding services at other locations such as schools, daycare, after school programs, etc. ABA services rendered by Morning Star ABA Therapy may or may not create the desired behavioral change in a child. ABA treatment comes with risks which may include an increase in problem behaviors, of which may be the original behaviors of concern. In many cases, problem behaviors get worse before they get better. There is a risk of problem behaviors permanently increasing in rate and or intensity and new problem behaviors may also emerge. By signing below you agree to hold Morning Star ABA Therapy harmless in the event your child’s behaviors become worse or do not get better. All fees for service are due regardless of the outcome of services. This agreement is binding, and failure to meet its terms will allow Morning Star ABA Therapy LLC to take certain recourse including further collection action. Insufficient payment and bounced checks will incur a fee of $30.00.By signing this agreement, all parties agree to the terms as described above. Invoices are mailed monthly and payment is due upon receipt. Payments accepted: Check and Credit Card. Credit Card payments can be made via the Pay My Bill tab at www.MorningStarABATherapy.com Make check’s payable to: Morning Star ABA Therapy.* This field is required.·
35
PRE-AUTHORIZATION FORM PAYMENT WITH DEBIT/CREDIT CARD:* This field is required.
Type of debit/credit card: American Express Visa MasterCard Discover, etc.
Debit/ Credit Card Number
CVV 3 digit code on the back of the card
Debit/ Credit Card Expiration date Month/ Year
36
CREDIT CARD SIGNATURE: I authorize Morning Star ABA Therapy (hereinafter known as the “Company”) to keep my signature on file to charge my debit/credit card, on an ongoing basis, for amounts I owe. I understand that I will only be charged for services that have been verified by the guardian who is present while the services are being delivered. understand that this authorization is valid indefinitely unless I cancel the authorization through written notice. I also agree to contact the Company if there are any changes to my charge account information.* This field is required.
37
Date of Client Intake Packet Signatures and Consent for ABA Treatment* This field is required.
Date
Year
Month
Day
38
Upload Diagnostic paperwork, the latest ABA assessment for your child and the front and back of your insurance card here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
Should be Empty: