CLIENT POLICIES AND CONSENT
Revised March 2024 -MD
Welcome to our infant stimulation program at A Step Ahead Pediatric Developmental Services, Inc. (ASAP) Our team of outstanding infant instructors and consultants are committed and dedicated in assisting you and your child’s developmental needs and education. In this guide you will find our program’s purpose, goals, anticipated outcomes, curriculum, policies, and additional resources. We look forward to working with you and your child and creating a professional and caring relationship. Your participation in our program is vital---you are an integral part of the team! Together we will make a difference!
PRIOR TO SERVICES
- All forms must be submitted online. If you do not have access to a computer, your information will be taken and inputted by one of our office staff members.
- Unless paying privately, authorizations must be in place prior to receiving services.
CONDITIONS OF TREATMENT
1. CONSENT TO TREATMENT/ASSESSMENT
I hereby consent to the administration and performance of all evaluation procedures and treatments within the realm of current standards of practice, which in the judgment of my child’s teacher may be considered necessary or advisable.
2. CONSENT TO TELEHEALTH TREATMENT
ASAP may recommend services through telehealth if clinically appropriate. I understand that my child will be receiving care through interactive audio, video, and other telecommunication technologies with a teacher who is not in the same physical location as me and my child. I understand that I am expected to provide a safe environment with minimized distractions for my child to participate in telehealth treatment. There is a risk of technology failure and interruption by a connectivity problem. I will need access to, and familiarity with, the appropriate, working technology for my child and me to participate in the services provided by ASAP, with a risk of technology interruptions. I also agree that my child and I are responsible for timely attendance, and that I remain responsible for adhering to ASAP’s “Third-Party Funders,” “Parent Presence,” and “Attendance” policies.
3. CONSENT TO USE OF THERAPEUTIC EQUIPMENT
I, on my behalf and on behalf of my child, fully understand that there is a risk of personal injury to my child in participating in play-based activities and other physically active games through the programs provided by ASAP. I am aware that my child is engaging in physically active games and/or therapeutic activities, which could result in injury. I am voluntarily allowing my child to participate in these activities and assume all risks of injury that may result. I personally, and on behalf of my child, agree to hold no individual or corporation responsible or liable for any injuries and associated costs that my child receives on account of these activities, including but not limited to ASAP, or it’s officers, employees, agents, aides, therapists, assistants, teachers, volunteers, successors, instructors, interns, insurers, or assigns (hereinafter “Releases”). I further agree to waive any claims or causes of action against and to hold harmless said Releases for any injuries or damages which my child suffers or might suffer as a result of the conduct of any person during or in conjunction with said physically active games or therapeutic play-based activities.
4. CONSENT TO PHOTOGRAPHY
I hereby agree to allow ASAP to take and/or use any pictures/tapes/videos/films of me or my child with my full knowledge and consent as a client of ASAP. This visual record may be used for teaching and training activities and/or as a part of my child’s medical/developmental record as ASAP may deem proper. My child’s identity will not be made public without my expressed permission for a specific occasion or purpose. Any use of my child for public relations will also require my specific permission and knowledge.
5. CONSENT FOR EMERGENCY TREATMENT
As the authorized representative, I hereby give consent for ASAP, to obtain all emergency medical or dental care prescribed by a duly licensed physician (M.D), osteopath (D.O.), or dentist (D.D.S.) for my child. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my child. My signature at the bottom of this form testifies that I am the authorized representative of the child named on this document. Further, I will be responsible for the charges for any medical or dental treatment or hospitalization rendered by reason of this authorization.
6. ILLNESS
I understand that in order to attend in person services, households must follow current CDC quarantine/isolation guidelines in case of a COVID-19 exposure or diagnosis (suspected or confirmed). I understand that if a child (or someone in the child’s home) experiences any symptoms of illness, the child should participate in telehealth until all symptoms (including, but not limited to, fever, vomiting, diarrhea, nasal congestion, cough, sore throat, skin irritation) have been fully resolved for at least 24 hours without medication. In the event that mild symptoms persist for more than 5 days, children may be allowed to return in person after presenting a doctor’s note indicating they are not contagious and/or a negative COVID-19 test. I understand that if a child shows symptoms of illness while receiving in person services, ASAP staff will separate them from peers and contact caregivers for immediate pick up.
7. RELEASE OF INFORMATION
I hereby agree that ASAP may release information, either written or verbal, regarding my child’s medical status and progress to professionals who have been or are currently involved in the treatment of my child. I hereby agree that, to the extent necessary to determine eligibility for services and to obtain reimbursement, ASAP may disclose portions of my child’s records to funding agencies such as health care insurance plans, school districts, and regional centers.
8. ATTENDANCE POLICY
It is extremely important to consistently attend appointments on time and avoid unnecessary cancellations. I hereby understand and agree to ASAP’s Attendance Policy.
- NO SHOW/LAST MINUTE CANCELLATIONS (NSLMC): Sessions are considered a "no show" if I have not communicated with ASAP within the first 15 minutes of the session. Sessions are considered “last minute cancellation” if I do not cancel within 2 hours of the appointment. Last minute cancellation and no show can result in my child’s therapy being terminated.
- First NSLMC: The administrator or teacher will provide a reminder.
- Second NSLMC: The referring agency will be notified of poor attendance.
- Third NSLMC: Services will be terminated.
- MULTIPLE CANCELLATIONS: All subsequent cancellations after two cancellations within a 6-month authorization period must be made up if the clinic has availability for make up.
- TARDINESS: You and your child are expected to be on time and ready for your child’s session. In the event that you are running late, you must notify the office and/or teacher. It will be in the therapist’s discretion to cancel or continue the session. Going over the scheduled time to make up for the missed time due to tardiness is not allowed.
- THERAPIST CANCELLATIONS: In the event that a session is canceled due to the therapist being ill or for personal reasons, a make up session will be offered if available. Make up sessions are not guaranteed to be completed by your child’s regular teacher. Sessions that are missed due to the teacher's vacation and/or continuing education are not guaranteed to be made up as teacher are mandated to take continuing education to keep current with the latest interventions. In addition, teacher are also entitled to vacations during the year. However, every effort to provide make up sessions will be made.
- THERAPIST TARDINESS: In the event the teacher foresees being over 15 minutes late, the teacher will call to notify you of their tardiness and expected time of arrival. It will be your discretion to cancel or continue the session. Additional time will be allotted to equal the missed portion due to the therapist’s tardiness.
- HOLIDAYS: Every effort to provide make up sessions for holidays will be made but not guaranteed.
- VACATIONS AND EXTENDED ABSENCES: Your current spot will be reserved for two weeks. If your vacation is longer than 2 weeks, your spot will be given to another client. When you return,we will re- assign you. However, it is not guaranteed that you will get the same teacher and that your services will start right away. You may be put on a waiting list.
- OTHER: All cancellations must be made up according to what is allowed and permitted by the referring agency. Make up sessions are not guaranteed to be with your regular teacher. Make up sessions will be offered via teletherapy if in person scheduling is not available.
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TELETHERAPY MAKE UP SESSIONS: Under the following circumstances, parents must be open to teletherapy to ensure their child's continued progress in therapy.
The State of California declares a state of emergency.
*The teacher will have the discretion to change service delivery to teletherapy for the safety of everyone and parents must be willing to do teletherapy if the teacher deems appropriate for the child. The original day and time will be kept the same if possible.
After 2 cancellations within a 6 month authorization period.
*Parents must be willing to do teletherapy, if teletherapy is the only available mode of session for make-up and the teacher deems appropriate for the child.
After each no show/last minute cancellation.
*Parents must be willing to do teletherapy, if teletherapy is the only available mode of session for make-up and the teacher deems appropriate for the child.
*Teletherapy will consist of a multitude of approaches and is NOT intended for the child to sit in front of the screen only. Teacher's teletherapy sessions are thoughtfully planned and are child and play driven.
9. PARENT PRESENCE AND PARTICIPATION
Sessions are provided individually or in group settings depending on the service/clinical recommendation. If my child is receiving services in a home or community, a caregiver must be present at all times. If my child is receiving services in the clinic, caregivers may remain in the waiting room or participate in the session as long as they are directly with their child and therapist. I understand that observing from afar, using cell phones, reading, or using a computer is not permitted within the clinic treatment space. Parent participation is always encouraged.
10. SIBLINGS AND ACCOMPANYING CHILDREN
I understand that caregivers are responsible for supervising all children brought to the ASAP waiting room, and that only children under direct care of a ASAP therapist may use equipment and toys in the treatment space.
11. DROP-OFF AND PICKUP
I understand that children must be monitored in the waiting room and cannot be dropped off unattended. If I or another caregiver is leaving the clinic, I/he/she/they must provide a phone number at the front desk in case of an illness or emergency. I understand that caregivers are expected to arrive at the clinic 5 minutes prior to the session ending for a prompt pick up.
12. NON-RESTRAINTS
ASAP does not follow any restrictive approach towards a child’s negative or aggressive behavior. ASAP does not use restraints, force, yell or scream to stop a child’s negative or aggressive behavior. ASAP uses a re-direction and sensory calming approach. In the event that these strategies do not work, it is expected that parents assist in managing the child’s behavior. For this reason, it is imperative that parents stay in close proximity to their child and do not leave the premises while the child is in therapy. I understand that ASAP does not use restraints and or any forms of restrictive approach towards a child’s negative or aggressive behavior.
13. EMERGENCY CONTACTS
I understand that ASAP may contact or release my child to emergency contacts I list on this form if a primary guardian is not available at the end of a session or program, or in the case of an emergency.
14. EMERGENCY EVENT
Following an emergency event, assuming conditions are deemed safe, children will be released to their guardians. If it is not feasible for a guardian to pick up a child, employees will take children to a verified safe location determined by the American Red Cross and/or communicated by the National Emergency Broadcast System.
15. RE-EVALUATIONS
Yearly evaluations are conducted for private pay clients per standard best practice guidelines. Evaluations for services through a funding agency are conducted according to the agency’s guidelines.
16. COVERAGE
At times, teachers will take time for meetings, continuing education, vacation, or sick time. When this impacts scheduled appointments, ASAP will provide coverage whenever possible.
17. VOLUNTEER/NEW HIRES OBSERVATION CONSENT
I give permission for volunteers or prospective employees to observe my child’s sessions.
18. TELETHERAPY/IN PERSON
I understand that I have the right to switch between in person service to teletherapy service at any given time and vice versa. However, I will need to give my therapist a minimum of 2 week notice to allow for proper scheduling. In addition, I understand that by choosing in person services, you, your child, and the rest of the family have a chance of possible exposure to COVID. I do not hold ASAP and staff at fault in case there is exposure to COVID.
19. TRANSLATION SERVICES
I understand that translation services are available for certain languages and that I give permission for translation as needed. However, translators may or may not be certified.
20. TREATMENT SESSION BREAKDOWN
- TELETHERAPY SESSION: Total 60 minutes broken down as follows
- 50 minutes: Tech set up/contact parents, direct therapy/session. Sessions to address goals, treatment plan, and parent education/question and answers.
- 10 minutes: Teacher to write daily treatment notes and plan for the next session. (completed outside the session)
- IN PERSON: Total 60 minutes broken down as follows
- 50 minutes: COVID screening process including handwashing, direct therapy, and parent training. Sessions to address goals, treatment plan, and parent education. Client check out/signatures obtained and answer any parent questions.
- 10 minutes: Teacher to write daily treatment notes and plan for the next session. (completed outside the session)
- END OF SESSIONS
I understand that discussions with caregivers about activities and goal progress are part of intervention. Teacher and children may arrive in the waiting room prior to the session ending to account for this if parents are not present during the session.
21. NON-DISCRIMINATION
ASAP strives to maintain an inclusive environment without discriminating on the basis of race, religion, sex, national origin, sexual orientation, age, or disability. I understand that I and other guardians of my child are expected to participate in this endeavor and show mutual respect for members of our community.
22. YOU AND YOUR CHILD’S HAVE RIGHTS
You understand that you and your child have the right…
- To be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy.
- To a prompt and reasonable response to questions and requests.
- To know who is providing medical services and who is responsible for his or her care.
- To participate in the development and implementation of the patient plan of care.
- To know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
- To know what rules and regulations apply to his or her conduct.
- To be given by the healthcare provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
- To refuse any treatment, except as otherwise provided by law.
- To be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care.
- To receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.
- To receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained.
- To impartial access to medical treatment or accommodations, regardless of race, national origin,religion, handicap, or source of payment.
- To treatment for any emergency medical condition that will deteriorate from failure to provide treatment.
- To express grievances regarding any violation of his or her rights, through the grievance procedure of the healthcare provider or healthcare facility which served him or her and to the appropriate state licensing agency.
23. A PATIENT/FAMILY/GUARDIAN IS RESPONSIBLE FOR
You understand that you have the responsibility to..
- Providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health.
- Reporting unexpected changes in his or her condition to the health care provider.
- Reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
- Following the treatment plan recommended by the health care provider.
- Keeping appointments and, when he or she is unable to do so for any reason, notifying the health care provider or healthcare facility.
- His or her actions if he or she refuses treatment or does not follow the health care provider’s instructions.
- Assuring that the financial obligations of his or her health care are fulfilled as promptly as possible.
- Following health care facility rules and regulations affecting patient care and conduct.
- Active participant during your child’s therapy session
24. GRIEVANCES
Clients that wish to file an internal grievance against the program must follow the following procedures. The following procedure will help the company address the client’s problems and/or concerns.
A. Dealing with Grievances Informally
- Clients are encouraged to talk to the office manager first in an attempt to resolve matters. This is a way to resolve problems quickly and easily.
- The clients shall call the main office and request to talk or meet with the office manager. A face-to-face meeting and/or a phone call must be completed within 5 days from the request.
- If the grievance does not get resolved through the informal process, the client will be advised to go through the formal grievance procedure.
- There are limits to the informal option. It is unlikely to be suitable for dealing with a very serious incident, as it will not involve a formal investigation. In situations where a more in- depth investigation and a disciplinary outcome may be needed, then the formal procedure would be more suitable.
B. Dealing with Grievances Formally
The formal procedure consists of the following step:
- Starting the Process: Complete a Grievance Form and send to Anna Holley, Program Director.
- Meeting: A formal meeting with the program director will be scheduled within 5 business days from the time the letter of complaint is received. Additional meetings may be held to meet with witnesses and other parties involved. All witnesses who give information will do so privately and not in the presence of anyone else who was involved in, or who was present during, the events giving rise to the grievance. All information or evidence provided by witnesses will be treated as confidential.
- Investigation: The program director will carry-out any further investigations that are necessary and will keep detailed and accurate records of all meetings.
- Decision: Having obtained all relevant information, the program director will consider whether the facts support the grievance and, if so, what disciplinary action, if any, needs to be taken, or whether other action is warranted. The manager will prepare a written report of the investigation and its findings. Within 10 working/business days, the client will be informed about the outcome of the investigation. This will be done in a meeting, if possible, and will be confirmed in writing.
- If the client is in disagreement with the final outcome, the referral/funding source service coordinator will be notified.
25. ADDITIONAL INFORMATION
- We expect your child to be awake and full during visits. Feed your child 30 minutes before the scheduled session and allow your child to nap prior to his/her session. *Unless it is feeding therapy, then discuss appropriate time for therapy with your therapist.
- Always sign the attendance sheet at the end of each session.
- ASAP is required by California State Law to report any case of suspected child abuse.
A STEP AHEAD PEDIATRIC DEVELOPMENTAL SERVICES, INC.
HIPAA NOTICE OF PRIVACY PRACTICES
(Effective April 14, 2003)
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.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice
while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we publish and issue a new one.
CHANGES TO THE NOTICE
We will abide by the terms of the Notice currently in effect. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all protected health information that we maintain. An updated version of the notice may be obtained from the Privacy Officer, whose contact information is provided at the end of this notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We disclose health information about you for treatment, payment, and healthcare operations. We also use this information for these purposes.
For Example:
Treatment: We may use your health information to provide occupational therapy services to you.
Payment: We may use and disclose medical information about you in order to receive payment from you for occupational therapy services rendered to you.
Appointment Reminders and Treatment Alternatives: We may use or disclose your health information to provide you with appointment reminders such as voicemail/text messages, postcards, or letters.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations.
Business Associates: We may use and disclose certain medical information about you to our business associates. A business associate is an individual or entity under contract with us to perform or assist us in performing a function or activity that requires us to disclose your health information to them.
To You, Your Family and Friends: We must disclose your health information to you, as described in the Information Rights section of this notice. We may disclose your health information to a family member, friend or other person to help with your healthcare or with payment for your healthcare, but only if you agree or do not object that we may do so, if you are not able to agree, if it is necessary in our professional judgment.
Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for assisting you to obtain healthcare services. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event you be come incapacitated, or during an emergency, we may disclose your health information to others, including healthcare providers, on the basis of our professional judgment
Required by Law: We may use or disclose your health information when we are required to do so by law, including disclosure for use in judicial and administrative proceedings, or to law enforcement officials, or to the proper authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.
Public Health: We may use or disclose your health information in connection with public health activities, health oversight activities, and with worker’s compensation matters. We may also disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose protected health information to a correctional institution or law enforcement official having lawful custody of an inmate or patient.
State Laws: The laws of the state where you are receiving your occupational therapy services from us may provide greater rights to you.
Your Authorization: In addition to our use and disclosure of your health information for the purpose described above, you may give us written authorization to use your health information or to disclose it to anyone for any purpose
YOUR INFORMATION RIGHTS
Although all records concerning your services obtained from us are our property, you have the following rights concerning your information.
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your information. We are not required to honor your request. We encourage you to make these requests in writing.
Right to Confidential Communications: You have the right to receive confidential communications of your information by alternative means or at alternative locations. We require that you make this request in writing.
Right to Inspect and Copy: You have the right to inspect and copy your information in most circumstances. We require that you make this request in writing.
Right to Amend: You have the right to amend your health information in circumstances where you believe that information is inaccurate or incomplete. We require that you make this request in writing, and that you tell us why you believe that we should amend your information.
Right to an Accounting: You have the right to request and obtain an accounting of certain disclosures of your information.
Right to Obtain Copy: You have the right to obtain a paper copy of this notice upon request. A request to exercise any of these rights must be submitted to the Privacy Officer. Forms to help you make your request are available from the Privacy Officer.
QUESTIONS AND COMPLAINTS
If you believe your privacy rights have been violated, you have the right to report such alleged violation to our office, and we will promptly investigate the matter. You may file a complaint with our office by contacting our privacy officer. We support your right of privacy and we will not retaliate in any way if you choose to file a complaint about our privacy practices. You may also contact the Secretary of Health and Human Services.
CONTACT
Anna Holley • 15454 Gale Ave. Suite F, Hacienda Heights, CA 91745 • (626) 330-1538
STEP-BY-STEP PEDIATRIC THERAPY, INC.
CONTACT INFORMATION
HACIENDA CLINIC:
15454 Gale Avenue, Suite F
Hacienda Heights, CA 91745
Phone: 626-330-1538
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WALNUT CLINIC:
18800 Amar Road Suite B14
Walnut, CA 91789
Phone: (626) 269-3040
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Admin Email: admin@asapdevelopment.org
Website: www.asapdevelopment.org
Fax: (626) 239-1868