Patient Registration Forms

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.

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.

If you have any questions regarding this notice, please contact our Privacy Officer at 781-239-0100.

OUR OBLIGATIONS
We are required by law to:

• Maintain the privacy of protected health information.
• Give you this notice of our legal duties and privacy practices regarding health information about you.
• Follow the terms of our notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION
Described as follows are the ways we may use and disclose health information that identifies you (“Health Information”).  Except for the following purposes, we will use and disclose Health Information only with your written permission.  You may revoke such permission at any time by writing to our practice’s privacy officer.

TREATMENT – We may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.

PAYMENT – We may disclose Health Information so that others or we may bill and receive payment from you, an insurance company, or a third party for the treatment and services you received.

HEALTH CARE OPERATIONS – We may use and disclose Health Information for health care operation purposes.  These uses and disclosures are necessary to make sure that all our patients receive quality care and to operate and manage our office.

APPOINTMENT REMINDERS, TREATMENT ALTERNATIVES AND HEALTH RELATED BENEFITS AND SERVICES – We may disclose health Information to contact you and to remind you that you have an appointment with us.  We also may use and disclose Health Information to tell you about treatment alternatives or health related benefits and services that may be of interest to you.

INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE – When appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend.  We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster or relief effort.

SPECIAL SITUATIONS
As Required by Law – We will disclose Health Information when required to do so by international, federal, state or local law. We will disclose Health Information in response to a court order, subpoena, warrant, summons or similar.

Business Associates – We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Health Oversight Activities – We may disclose Health Information to a health oversight agency for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections, and licensure.  These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Workers’ Compensation – We may release Health Information for workers’ compensation or similar programs.  These programs provide benefits for work-related injuries or illnesses.

YOUR RIGHTS
You have the following rights regarding Health Information we have about you:

• The right to inspect and copy
• The right to amend
• The right to an accounting of disclosures
• The right to request restrictions or limitations on the Health Information we use or disclose for treatment, payment or health care operations.
• The right to request confidential communication (you can request we contact you in a certain way or location)

Complaints

 If you feel that your privacy rights have been violated, you have the right to make a complaint to us in writing without fear of retaliation.  Your complaint should contain enough specific information so that we may adequately investigate and respond to your concerns.  

Privacy Officer Contact information:

Janet Crew Wade

The Boston Ability Center

49 Walnut Park, Building #3

Wellesley Hills, MA 02481

(781) 239-0100     

INSURANCE

IN NETWORK BILLING

• The Boston Ability Center is currently an in-network provider with Blue Cross Blue Shield of MA, Mass General Brigham's Health Plan (previously Allways Health Care), and Tricare. The patient’s insurance card is required prior to the first visit, and a photocopy of the card will be kept on record. All co-payments and past due balances are due and payable at the time of service.
• Once a patient’s insurance benefit is exhausted, either by way of time elapsed or visit count, the patient is responsible for payment for treatment in full at the time of service.  See self-pay information below.
• If you have filed or plan to file an appeal with your insurance company for denial of services for any reason, you are responsible for payment in full within 30 days of the time of service for the duration of the appeal process. Upon resolution of the appeal, if the claim is paid by the insurance company and a check is received by The Boston Ability Center, the credit balance will be refunded.

NON-PARTICIPATING INSURANCE PLANS (SELF-PAY)

Self-pay accounts include:

• Patients covered by insurance plans with which The Boston Ability Center does not participate
• Patients without an insurance card on file
• Patients who have exhausted their insurance benefit (maximum number of covered visits has been used)
• Patients receiving non-covered treatments: Not all treatments are considered to be medically necessary and therefore will not be paid by some insurance companies.  We will do our best to inform you ahead of time for any treatments which have in the past been denied for this reason.   You will be responsible for payment should treatment be denied for this reason.

If you do not have BCBS, Mass General Brigham's Health Plan (previously AllWays), or Tricare as an insurance carrier, the cost of services at The BAC will be self-pay at the time of service and claims will not be sent to the insurance carrier. BAC does not have contact with your insurance and will not request prior authorizations, request visit extensions, file appeals, or submit medical records or any additional requirements that may be needed by your insurance. We cannot accept in-network provider exception agreements, in-network payment agreements, or single case agreements with your insurance company. If you are hoping to submit to insurance for personal reimbursement, it is your responsibility to confirm coverage as well as complete all necessary requirements, such as prior authorizations. The Boston Ability Center will provide the patient with the following upon request: documentation for the initial evaluation and any subsequent re-evaluations (completed yearly), a progress note every 8 weeks, and detailed receipts that include industry-standard codes. All reimbursement checks should be sent directly to the patient and if a check is received by The Boston Ability Center, it will be forwarded to the patient.

The responsible party shall pay in full at the time of service. The Boston Ability Center maintains the right to deny services to self-pay accounts that are past due. The out-of-pocket rate for a 45-minute physical therapy, occupational therapy or speech therapy session is $165.00. 

REFERRALS For all of the above insurance scenarios, if you are required to have an authorization in place prior to receiving care from a specialist, please contact your primary care doctor prior to your appointment. This is the patient/family responsibility.

DUAL INSURANCES- If both parents have insurance coverage, the primary insurance is determined by “The Birthday Rule”. The dependent children are covered first by the health plan of the parent whose birthday falls earlier in the year.  The other parent holds the secondary coverage. The patient (parent) is responsible for keeping BAC Billing department up to date on all insurance plan information that may impact the billing process for services received at the BAC.

VISIT COUNTS – if your coverage has a limit on visits per discipline in a year, you are responsible for keeping track of the number of visits your child has received. If you exceed the visit limit, all services after the limit has been reached are billed as self-pay. If your child was previously or is currently receiving OT, PT or speech/language therapy elsewhere, please let us know and please include those visits towards your visit count.

SAME DAY TREATMENT– Some insurance companies limit what is paid toward rehabilitation therapy and will not pay for PT and OT treatments performed on the same day.  If both services are performed on the same day, you will be responsible for payment of the uncovered service.

CHILD CUSTODY CASES- The parent with primary custody is usually the parent with whom the child lives and who usually brings the child to The Boston Ability Center for care. The custodial parent is responsible for co-payments at the time of service for participating insurances and for all past due balances. If the non-custodial parent carries the in-network insurance, The Boston Ability Center will bill that insurance company. The Boston Ability Center will not get involved with divorce settlements i.e.; one parent pays 80% and the other parent pays 20%. It is the parents’ obligation to work out an agreement and insure prompt payment to Boston Ability Center.

PATIENT REFUNDS- The following criteria must be met prior to issuing a patient refund; there are no outstanding insurance claims on the family’s account, and there are no outstanding patient balances on the family’s account.

PAYMENT PLAN AGREEMENTS– The Boston Ability Center is willing to extend payment plan agreements to patients with special financial needs.  Each agreement is unique to each family’s situation. Please contact Janet Wade, Boston Ability Center Director, to request special arrangements.

The Boston Ability Center requires every account to have a valid credit card on file in our secure system.

If you have questions about the BAC’s financial policies, please feel free to speak to us. By signing below, I acknowledge that I understand and agree to the BAC’s financial policies

Thank you for choosing the Boston Ability Center. We are so excited to get to know you and your child! I understand and agree to adhere to the appointment policy.

You can request that additional reminders be sent to other e-mails or cell numbers, such as a nanny or caregiver. If you would like to do so, please notify the front desk and they would e happy to assist you.

Staying in communication with your child’s team of care providers allows our clinicians to provide the best collaborative care possible! Please use this form to list any providers with whom you would like your child’s clinician to communicate (physicians, teachers, care providers, other therapists, etc.) If you would like a copy of your child’s evaluation report to be sent to your child’s pediatrician, please be sure to list them on this form! 

I hereby authorize The Boston Ability Center to release and request any medical or school related information as requested below.

Information will not be released without a valid signature below. This authorization grants permission for the release of information until the minor's age of majority. I can however, cancel this authorization in writing at any time, except to the extent that the Boston Ability Center has relied on it. For example, if I cancel after the Boston Ability Center has sent requested records, the Boston Ability Center will not retrieve those records. Please notify in writing if you wish to cancel the future release of information.

I hereby grant The Boston Ability Center permission to use my child’s likeness in a photograph or video in any and all of its publications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of The Boston Ability Center and will not be returned. I hereby irrevocably authorize The Boston Ability Center to edit, alter, copy, exhibit, publish or distribute photos for purposes of publicizing The Boston Ability Center’s programs or for any other lawful purposes. In addition,I waive the right to inspect or approve the finished product, including written or electronic copy, wherein the likeness of my child appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of photographs. I hereby hold harmless and release and forever discharge The Boston Ability Center from all claims, demands, and causes of action which I, my heirs, representatives, administrators, or any other persons acting on my child’s behalf.

I understand that the laws that protect the privacy and the confidentiality of my child’s medical information also apply to teletherapy.

I understand that while teletherapy treatment has been found to be effective in treating a wide range of disorders, there is no guarantee that all treatment of all clients will be effective.

I understand that there are potential risks involving technology, including but not limited to: internet interruptions and technical difficulties. I understand that technical difficulties with hardware, software, and internet connection may result in service interruption and that the we are not responsible for any technical problems, nor do we guarantee that services will be available or work as expected. I understand that I am responsible for information security on my computer and in my own physical location and that although HIPPA compliant, ZOOM and any other technology used by the Boston Ability Center to deliver teletherapies may be vulnerable to breaches in security. I understand that I am responsible for creating and maintaining a username(s) and password(s) and that it is my responsibility to keep these secure. I understand that I am responsible to ensure privacy at my own location by being in a private location so other individuals cannot hear my or my child’s conversations.

I understand that either I or BAC’s speech-language pathologist, occupational therapist or physical therapist can discontinue the teletherapy services if it is felt that this type of service delivery does not benefit my child’s needs or for any other reason.

By signing you agree to have read, understand and agree to all the above:

BAC staff are committed to meeting the needs of all children and working collaboratively with families to help children achieve their toileting goals. As such, BAC staff are happy to assist children with toileting as needed and will take all reasonable precautions to ensure the safety, privacy, and dignity of each child when providing toileting assistance. Depending on your child's needs, this may include tasks such as diaper changing, helping a child access the toilet, assisting a child with wiping or managing clothing, assisting a child with hand washing, and/or changing a child following an accident.