Consent Forms

Early Bird Consent Forms
Client Name: First Name*   Last Name*   Client DOB: DOB*

Name of Person Filling out Form:   First Name*   Last Name*
Area Code and phone number*      Email*
Relationship to Child:   Relationship*
Exchanging Information

I give my voluntary consent for Early Bird Developmental Services to use and disclose health information regarding First Name* Last Name* to carry out treatment, payment and health care operations. In addition to sharing health information with my insurance company/Medicaid if requested and acquiring physician orders, I authorize Early Bird Developmental Services to exchange health information with the following agencies or person(s): Name* (list out any agencies with whom we can exchange information such as your pediatrician, school, etc.)
Electronic Communications
Electronic Communications authorize Early Bird Developmental Services to leave a message on voicemail or with a person at a designated telephone number(s). I authorize Early Bird Developmental Services to text my cell phone or the cell phone of the caregivers as appropriate. I authorize Early Bird Developmental Services to send e-mail(s) that contains health information to me at a designated address to carry out treatment, payment, and health care operations. I understand that I may revoke these consents at any time by not notifying Early Bird Developmental Services.*

I DoI Do Not
Consent for Treatment, Payment, and Operations

By signing this form, I am consenting to Early Bird Developmental Services' use of and disclosure of my child's protected health information for treatment, payment, and health care operations. I understand that I do not have to consent to the use or disclosure of my child's protected health information for treatment, payment, and health care operations, but if I do not consent, Early Bird Developmental Services may refuse to provide me health care services. I understand that I can request more information at any time about how Early Bird Developmental Services uses or discloses protected health information to carry out treatment, payment, and health care operations. I understand that I can revoke this consent at any time. This consent is effective until the above-named client is discharged by Early Bird.
I fully understand this document and give my consent.

Signature: Signature*   Printed name: First Name   Last Name
Relationship to Client: Relationship*
Today's Date:  Today's Date*

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This is a summary. For the full text of this notice visit www.earlybirdonline.com. For more information or assistance, or to request a printed copy of the full text this notice, contact Robert Kornfeld, Director of Operations, 704-9995-2929 or bob@earlybirdonline.com

Your Rights

You have the right to:
- Get a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential Communication
- Ask us to limit the information we share
- Get a list of those with whom we've shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
Your Choices

You may permit - or deny us permission - to use and share your information in certain ways. Without express written permission WE WILL NOT:
- Tell family and friends about your condition
- Include you in any directory
- Use your information for marketing or other purposes
Our Uses and Disclosures

We may use and share your information as we:
- Treat you
- Run our organization
- Bill for your service
- Help with public health and safety issues
- Do research
- Comply with the law
- Work with a medical examiner or funeral director
- Address workers' compensation, law enforcement, and other government requests
- Respond to lawsuits and legal actions
I acknowledge by signing below that I have received and read/had explained to me Early Bird Developmental Services' Notice of Privacy Practices

Signature: Signature   Printed name:       First Name   Last Name
Relationship to Client:     relationship to client
Today's Date:     Date

Consent for In-Person Services during Pandemic

This document contains important information about our decision (yours and mine) to resume in-person services during the COVID-19 pandemic. We will return to teletherapy services if lockdown orders are again imposed by local, state or federal authorities, if other health concerns arise, or at any time you or I feel it is safer to do so.

By Signing below, I acknowledge that there are risks associated with in-person services during a pandemic.

Our responsibilities to minimize exposure

To begin or resume in-person services, I agree to take certain precautions which will keep everyone (you, me, our families, and other patients) safer from exposure to the virus that causes COVID-19. If we do not adhere to these safeguards, it may necessitate a return to teletherapy services.
- We will only keep appointments if we are symptom-free. We will cancel appointments (with as much notice as possible) should we or anyone in our household exhibit symptoms or believe they may have been exposed to the virus that causes COVID-19. We will answer the screening questions before each visit and if we cannot answer "no" to every question we will not have a visit.
- We will limit the number of people involved in the visit to include only primary caregivers, the patient and the clinician. Anyone else living in the hopusehold will need to stay away from the location where the therapy is provided.
- We will all wear masks or other facial covering during the visit and will maintain a distance of 6 feet. There will be no casual physical contact (hugs or handshakes, etc.) and only contact with the patient when medically neccessary.
- We will wash hands upon entering your house (please have soap and towels available) and will wash hands prior to leaving. We will try not to touch our faces and will wash hands and face if we do so.
- We will do our best to limit exposure between visits by practicing Governor Cooper's Three W's - washing hands, waiting (social distancing), and wearing a mask.
- We will immediatly inform one another if we have had an exposure, or if anyone in our households has tested positive for the virus that causes COVID-19, and will resume treatment via teletherapy platform.
This agreement supplements the original Consent for Treatment, Payment, and Operations that I signed at the start of our work together. Your signature below indicates that you agree to the above conditions.
Signature

Clear

Tele-Health Informed Consent Form
I hereby consent to engaging in telehealth with Early Bird Developmental Services for my child as part of their therapy course of care. I understand that "telemedicine or telehealth" includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telehealth also involves the communication of my medical/mental information, both orally and visually, to health care practitioners.I understand that I have the following rights with respect to telehealth: I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment, or risking the loss or withdrawal of any benefits to which I would otherwise be entitled. The laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential.I understand that there are risks and consequences from telehealth, including but not limited to, the possibility, despite reasonable efforts on the part of my therapists, that: the transmission of my medical information could be distrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.*

I DoI Do Not
Signature: Signature Printed name:   First Name   Last Name
Relationship to Child:  Relationship
Today's Date: Today's Date

Client Guide to Company Policies

FINANCIAL RESPONSIBILITY, BILLING & PAYMENT

It is your responsibility to pay for all services rendered. We are in-network with most major insurance companies and will file our claims with your insurance company or another payer for services rendered on your behalf. We will verify your insurance benefits with your carrier and provide you with a good-faith estimate of your out-of-pocket costs for our services, but it is important to understand that we do not guarantee this information. Insurance companies do not guarantee payment; payment is determined at the time we file each claim (each time a service is provided).

Knowing your benefits is ultimately your responsibility, and we strongly encourage you to call your insurance company directly or use an online portal to review your benefit information as it applies to our services. If you have a change in insurance or Medicaid status, you must inform your therapist or call the office immediately at 704-846-0262.

Once we have received a reply from your insurance or other payer for each claim, we will bill you on the 15 th of each month for your portion of our charges, if any. (This process can take several weeks.) Please do not pay your therapist directly.

If you prefer, an interest-free Equal Payment Plan is available. You may pay your out-of-pocket costs in 12 or 24 equal monthly installments. A credit/debit/HSA will be kept on file and automatically charged each month. You will get a receipt for each payment by email and continue to receive monthly statements showing all charges and credits.

To request paperless statements or set up an Equal Payment Plan, please contact Bob Kornfeld at 704-995-2929 or bob@earlybirdonline.com. To pay your bill online go to www.earlybirdonline.com and look for the “Make Payment” tab at the top of the page. Unpaid balances may incur late charges or lead to suspension of services. Delinquent balances or returned checks may be referred for collection and incur additional costs.

Please sign here to indicate that you have carefully read and understand Early Bird’s Financial Responsibility Policy:
Signature

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Signature

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Full Name

First NameLast Name
Relationship to the child
Relationship to the child

MISSED SESSIONS & CANCELLATIONS
- Client Cancellations – If you need to reschedule a therapy session, we ask that you call the therapist before 8:00 pm the day before the scheduled session. If you will not be home at the time of a scheduled appointment, please be respectful by giving notice. A therapy session should not take place if your child has had vomiting, diarrhea or fever within 24 hours of the appointment time. If therapy appointments are repeatedly missed or cancelled, therapy may be terminated at the discretion of Early Bird. Three no-shows within a two-month period may result in a termination of services.
- Therapist Cancellations – You will be notified at least one week in advance for all planned cancellations and as soon as possible for emergency cancellations. Cancelled sessions will be rescheduled whenever possible.
- Make-up sessions – In Mecklenburg County, sessions provided for children enrolled in early intervention through the CDSA may only be made up within the same week as the scheduled service. Outside Mecklenburg County, therapists are allowed makeup visits within 30 days, within the authorization period, documenting the date and reason for the makeup. We cannot makeup visits in advance.
- Schedule changes – We do our best to accommodate each family’s schedule while striving to serve as many families as possible. For this reason, as new children are added to our caseloads, it is occasionally necessary to ask existing clients to adjust their scheduled therapy times. If this becomes necessary, your therapist will discuss these possible changes with you.
- Clinic sessions – Please plan to arrive at the clinic on time for your scheduled session. We ask that you remain on premises during your child’s session but if you must leave, please provide your therapist with your current contact information. Remember to return 5 to 10 minutes early for pick up to allow adequate time for your therapist to update you regarding your child's
  session. If you need to reschedule a clinic session, we ask that you call the therapist before 8:00pm the day before the scheduled session. If clinic appointments are repeatedly missed or cancelled, therapy may be terminated at the discretion of Early Bird. Three no-shows within a two-month period may result in a termination of services.
Please sign here to indicate that you have carefully read and understand Early Bird’s Cancellation, Scheduling, and Make-up Policy:
Signature*

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Date

MonthDayYear
Date
Name

First NameLast Name
Relationship to client
relationship to client

CAREGIVER PARTICIPATION
- Early Bird expects parents and caregivers to be active participants in therapy so that techniques demonstrated can be incorporated into your child’s daily routine.
- Therapy may be provided in your child’s natural environment or in our clinic. In the natural environment the therapist may occasionally bring toys or other materials (books, adapted toys, etc.) that in their professional opinion might enhance your child’s development.
- Therapy sessions are typically 30 to 60 minutes once or twice a week depending on medical necessity and specified treatment plans. This time may include direct therapy, parent or caregiver education, and consultation to ensure that all parties are involved in the treatment process.
LANGUAGE ASSISTANCE

It is Early Bird’s policy to provide Medicaid members with limited English skills the language assistance necessary in order to afford them meaningful and equal access to the Medicaid benefits and services to which they are entitled, in accordance with Title VI of the Civil Rights Act of 1964 (42 U.S.C. §§2000 et. seq.) and regulations pursuant thereto (45 C.F.R Part 80).

YOUR QUESTIONS AND CONCERNS

In order for us to be successful in our intervention, we must work together and have an open and honest relationship. If you are having difficulty regarding scheduling appointments, treatment techniques used, or any other aspect of the therapeutic process, please express your concerns to your therapist, or directly to Early Bird Clinical Director Sherry Kornfeld at feedback@earlybirdonline.com or 704-846-0262.

I acknowledge by signing below that I have read and understand the Early Bird Client Guide to Company Policies:
Name: First Name* Last Name*
Today's Date:Date* Relationship to child: relationship to child
Signature*

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