Intake Application

In addition to completing the enclosed paperwork, we request that you upload, email, or fax us the following documents:

• copy of insurance card (front and back),
• proof of the client’s medical diagnosis (diagnostic testing results) 
• a physician’s script for ABA assessment and treatment.

These documents are required in order to request an authorization for ABA services through most insurance providers. Our staff will confirm when all required documentation has been received. Please contact us directly with additional questions. We look forward to serving your family.

Best,

The Behavior Doc

P: 540.738.7720

F: 540.779.0728

doc@thebehaviordocaba.com

Patient Name  {patientName}        Date of Birth {patientDate}

• I understand that The Behavior Doc, LLC cannot guarantee that the Recipient will not redisclose my health information to a third party. The Recipient may not be subject to federal laws governing privacy of health information.
• I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from The Behavior Doc, LLC.
• I understand that I may revoke this Authorization in writing at any time, however, l cannot revoke authorization for action that has already been taken. I further understand that I must provide any notice of revocation in writing to the Business Office at the address listed above.

A copy of this release shall be valid as the original. THIS CONSENT EXPIRES I YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.

• Caregiver Involvement: Caregivers are expected to participate in sessions and may have associated caregiver goals included in the treatment program. Caregiver training is designed to increase the caregiver’s ability to provide behavior support to the client when the treatment team is not present.
• Cancellations: TBD requests 24-hour notice should a session need to be canceled or rescheduled. Appropriate means of communication are a direct phone call to the lead analyst assigned to the case or an email to the provider. Should a provider arrive at the client’s home and the client is not present, the provider will wait 15-minutes prior to canceling the session. Should clients need to cancel or reschedule sessions with frequency (e.g. 20% of sessions in a month), services may be terminated.
• Communication: TBD requests that correspondence regarding treatment goals and content be restricted to scheduled session times between the caregiver and lead analyst (BCBA). Brief communication regarding appointment status, cancelations or rescheduling sessions, may be conducted via email, phone or text messaging with the lead analyst and other members of the treatment team. Interactions between TBD providers and clients should be respectful and courteous.
• Confidentiality: Following HIPAA guidelines, all confidential information and records will be properly stored and maintained. Providers will not discuss information disclosed during the discussion without a signed Release of Information (ROI) on file. Preventing Spread of Illness. Clients acknowledge that human contact increases the risk of spreading illness. In accordance with CDC guidelines (e.g. COVID-19), clients are to avoid in-person services if they are experiencing fever, vomiting or any other sign of illness within the previous 24 hours. This includes if the client is in the presence of another person or family member exhibiting signs of illness.
• Service Location: Services will be provided wherever the targeted behaviors are most prevalent, which may include the home, school or community settings. The caregiver or a responsible adult (over the age of 18) is required to be in the home for the full duration of in-home sessions. The environment selected for services must be clean and free from distractions that could impede on the delivery of services.
  
  I have carefully read and acknowledge the Patient Responsibilities.

I provide The Behavior Doc with informed consent to provide ABA services to my child. I understand that ABA services are designed to treat behavior challenges and may require intensive supports to treat my child. Risks involve include increased rates of problem behavior and unintended injury with the introduction of treatment programming.

In addition, I understand that often parent participation is required for ABA treatment to be effective and agree to participate as needed and as is written into the behavior assessment and support plan (BASP).

I acknowledge that I am the legal guardian of the client receiving services and have the ability to consent for ABA treatment under the supervision and care of The Behavior Doc. Should my legal guardian status change, I agree to notify The Behavior Doc immediately with the contact information of the named legal guardian. The Behavior Doc’s ABA services are contingent on guardian cooperation and participation and are subject to termination following a 30-day notice. The guardian may terminate services at any time and will be held responsible for any outstanding balances.

Steps for Filing a Grievance:

1. Document the event or ongoing events that are being reported. Include dates, times, personnel involved and the nature of the concern.

2. Submit documentation to TBD admin and Leadership. Email: doc@thebehaviordocaba.com.

3. Should written documentation or access to email not be available, please contact our corporate office via phone. Phone: 540.738.7720.

My signature acknowledges that I have received and read the steps necessary to file a grievance with The Behavior Doc LLC.

Child's Name   {patientName}

This agreement is entered on the date of signature, between The Behavior Doc, LLC, (PROVIDER) and {name} (RESPONSIBLE PARTY) for ABA Services rendered to {childsName} (CLIENT) by PROVIDER.

The RESPONSIBLE PARTY agrees to compensate PROVIDER for all ABA Services rendered to include any of the patient’s out of pocket, co-pays, and deductible expenses until all these patient responsibilities have been fully met for that calendar year. The RESPONSIBLE PARTY agrees to compensate the PROVIDER by paying all invoices in full upon receipt for all CLIENT responsibilities that the Insurance Company does not reimburse to the PROVIDER.

I, {name} (RESPONSIBLE PARTY) have reviewed and understand the terms of this agreement. I understand that I am responsible for payment in full to the PROVIDER at the time the invoice for services is received. Any outstanding balance will be billed to the credit card left on file bi-weekly. I also recognize that failure to make payment as stipulated will result in action to facilitate recovery of funds and will signify that I am choosing to place ABA services for my child on hold until the appropriate funds are recovered.

IN WITNESS WHEREOF, the parties hereto have fully executed this agreement effective the date first above written.