I understand the Boston Ability Center will contact 911 in case of a medical emergency. I assume all financial responsibility in case of a medical emergency, medical injury including transportation.
I understand that, for the safety of my child, there is video surveillance in all common areas at the Boston Ability Center.
Consent: I give The Boston Ability Center consent to provide evaluation and treatment and to use or share my protected health information to obtain payment for my bills or to conduct its healthcare operations and business. I authorize payment to be made directly to The Boston Ability Center including Medicare, Medicaid or other benefits payable from any source, for all services rendered. I understand that I am ultimately responsible for payment of my account, and accept full responsibility for the cost of all services. I realize that I have the right to refuse any procedure after having the risks and benefits explained to me. The Boston Ability Center Summary Note of Privacy Practices was given to me. The Boston Ability Center is hereby released from all legal liabilities.