A. The Program:
A1. This Service Agreement is entered into the date as noted below, between the parent(s) and/or legal guardian(s) of the patient as noted below and ABA Programming, Inc. d/b/a The Applied Behavior Center for Autism (“ABC”).
A2. ABC will provide services to the patient starting on or about the date of this Agreement. This Agreement shall continue in full force and effect unless the Parent/Guardian provides thirty (30) days written notice of termination of the Agreement to the Branch Manager and Program Coordinator where the patient receives services.
B. Responsibilities of Parent/Guardian:
B1. The Parent/Guardian shall provide at least one (1) business day prior notice to applicable Branch Manager when the patient will be absent. A 15-minute prior notice is required to the Branch Manager in an emergency as deemed as such by the Branch Manager. Failure to provide said notice without a deemed emergency may result in a charge of $50.00 for each day notice is not provided. This daily fee may also apply to absences during the thirty (30) day notice of termination by the Parent/Guardian. These fees are not covered by your insurance and are the responsibility of the parent/guardian. Payment in full is due upon the last day of services.
B2. The Parent/Guardian agrees to provide transportation of the patient to the center where the patient receives services on a daily basis unless a different transportation arrangement is agreed upon in writing with the Branch Manager.
B3. The Parent/Guardian shall furnish all emergency contact information, educational history, medical history, and requested medical information prior to the provision of services and any time there is a change in the information. Special instructions detailing emergency procedures requested by the Parent/Guardian shall be provided to the Branch Manager in writing.
B4. The Parent/Guardian shall not interrupt any instruction of any patient, including his or her own child, during the therapy day unless safety is eminent (self-injury, aggression, or property destruction) or directed to do so by ABC staff.
B5. The Parent/Guardian shall attend meetings as scheduled by ABC for updating ITP, BIP or progress report meetings.
B6. The Parent/Guardian is responsible for attending parent training meetings on a regular basis.
B7. The Parent/Guardian acknowledges that the instructor/technician is an employee or agent of ABC and, therefore, the Parent/Guardian shall not solicit, entice, or otherwise promote the discontinuation of that relationship by a job offer or otherwise.
B8. The Parent/Guardian shall provide any and all special equipment required to safely and professionally care for the patient during therapy service hours such as diapers, wheelchairs, etc.
C. Application, Fees, Payment and Other:
C1. By execution of this Agreement, the Parent/Guardian assumes personal responsibility for the payment of all fees, deductibles, co-pays, co-insurance and other charges and agrees to the rules and regulations of ABC and the provisions of the Parent Manual, as revised from time to time.
C2. All payments should be made payable to “ABC for Autism” attention “Payments” via mail, in person to our Indianapolis North- Corporate office, or online at www.appliedbehaviorcenter.org.
C3. The Parent/Guardian is responsible for knowing all related costs such as deductible, co-pays, coinsurance and out of pocket cost.
C4. The Parent/Guardian shall provide the patient with a nutritious lunch and other appropriate food and beverages. Otherwise, the Parent/Guardian will be contacted to provide the patient’s lunch.
C5. ABC will bill and, to the extent authorized, be reimbursed by applicable insurance companies, grants or other funding sources for services provided to the patient. The Parent/Guardian shall forward all explanations of benefits (EOB) reports and checks sent directly to the Parent/Guardian by insurance, endorsed and made Payable to ABC.
C6. ABC will generate patient statements via email or via postal mail if there is not an email address on file. It is the responsibility of the parent/guardian to update the Branch Manager AND the Billing Department of any changes including contact information. Please see the Parent Manual for further details.
C7. All patient invoices and accrued fees are due within 30 days of the statement date. Balances more than 31 days will include a 2% late fee. A second invoice will be sent after 31 days. At 91 days, your account may be sent to a collections company. [You are encouraged to request a payment plan from the Billing Supervisor.]
C8. Should suit be brought by ABC to enforce or interpret any part of this Agreement or for damages due to breach of any part of this Agreement, including, without limitation, to collect amounts and charges past due hereunder, ABC shall be entitled to recover costs of the suit, including reasonable attorneys’ fees, if ABC is the prevailing party. Any legal proceedings must be brought in Marion County, Indiana.
C9. (Medicaid Services Only) In accordance with Indiana Law, provider agrees not to bill members, or any member of a recipient’s family, for any additional charge for Indiana Health Coverage Program covered services, excluding any co-payment permitted by law.
C10. Certified staff of ABC will administer first aid/CPR to an injured patient. The Parent/Guardian will be contacted if, in the judgment of ABC staff, the patient needs immediate medical attention. If unable to reach the Parent/Guardian, ABC staff will make necessary medical arrangements for emergency treatment. The payment of all charges in connection with these medical arrangements shall be the responsibility of the Parent/Guardian.
D1. Parent/Guardian has the legal right to request inspection, review, and/or obtain copies of any medical records relating to services provided to the patient that are collected, maintained, or used by ABC. Any such request must be made in writing to the CEO, who shall review and respond to the request without any unnecessary delays. Records are typically released within 5-10 business days. Fees for records apply for outside agencies, attorneys, or other parties at $0.25/page due prior to release of such records. For further explanation of these and other rights regarding the patient’s protected health information, please refer to the Parent Manual.
E. Termination of This Agreement:
E1. This Agreement shall not be modified by any party by oral representation made before or after the execution of this Agreement. All modifications must be in writing and signed/initialed by the Parent/Guardian and by the CEO or President of ABC.
E2. This Agreement may be terminated immediately without prior written notice by ABC for the following reasons, including but not limited to, legal matters, safety issues and situations that may result in imminent danger or harm. ABC will strive to coordinate and transition medical records and care to another provider in the event of termination of the Agreement.
E3. If the Parent/Guardian fails to comply with any obligation in this Agreement or fails to comply with any rule, regulation, or requirement of ABC, a thirty (30) day written notice to terminate services will be issued:
If the Parent/Guardian fails to cooperate with ABC with respect to the provision of services to the patient, including but not limited to, failing to attend conferences with therapy personnel regarding matters that potentially warrant termination of the Agreement;
If ABC in its sole discretion determines that it is unable to satisfy the therapeutic needs of the patient or family; or
If ABC, in its sole discretion, determines that it is not in the best interest of ABC to continue with the Agreement.
Upon termination of this Agreement, Parent/Guardian agrees to discuss with ABC any new provider information, the needs of the patient, and to facilitate the patient’s transition from ABC’s care. Parent/Guardian understands that they have the responsibility to contact ABC to arrange for the patient’s transitioning including medical records from ABC.
F1. I hereby agree to comply with the policies, rules and regulations of ABC.
F2. I agree to pay the fees, comply with attendance policies, and other written policies.
F3. My signature below indicates that I have read the terms of this Agreement and that I have read the rules, regulations and manuals promulgated and provided by ABC. It further indicates that I have had this material explained to me and that all of my questions have been satisfactorily answered.