AIA Learner Social Club Intake Agreement Form

Dear Valued Family,

Thank you for selecting the Arizona Institute for Autism, LLC to help you meet the needs of your child. We appreciate you for having selected us to work with your child and family.

This packet of information will help inform you about Arizona Institute for Autism, LLC policies and procedures, and will allow you time to gather information prior to your intake appointment.

Thank you for the trust that you are placing in us to assist you and your family. We understand that some of these forms may be challenging, time-consuming, and in some places redundant.

We want you to know that the more information that we have the better able we will be to assist you and your family. If at any time in this process you have any questions please contact us.

We look forward to meeting you and your child. 

Sincerely,

Rula Diab, Clinical Director

M.Ed, BCBA, LBA 

At the Arizona Institute for Autism LLC our trained providers work with children in a group setting closely monitoring emotional responses in order to match the difficulty of the material and method of instruction to the child’s ability level and rate of learning. All our providers hold at least a bachelor's degree or have equivalent extensive training specifically in research-supported treatments for autism spectrum disorders.

All learners need opportunities to have fun, connect with others and make friends, while learning and developing new skills. Our goal is to help your learner stay well and increase emotional and social functioning by providing quality-enriched programs. With evidence-based integrated wellness enrichment services such as music, art, games, dance, and recreational fun, our Learner Social Club not only saves you time but most importantly, treats your learner’s whole mind and body.

Effective Learner Social Club provides the following:

• Provides 1:5 Learner to provider ratio
• Provides structure and predictability
• Breaks down abstract social concepts into concrete actions
• Simplifies language and group children by language level
• Works in pairs or groups with cooperation and partnership encouraged
• Provides multiple and varied learning opportunities
• Fosters self-awareness and self-esteem
• Provide opportunities for practice so that skills are used beyond the group in real life setting

This document describes the nature of the agreement for professional services, the agreed upon limits of those services, and the rights and protections afforded under the Behavior Analyst Certification Board’s Guidelines for Responsible Conduct for Behavior Analysts. I will receive a copy of this document to retain for my records. All fees for services and payment arrangements will be reviewed separately.

1. I, the undersigned (parent/Legal guardian), hereby agree to have my child participate in the Learner Social Club through Arizona Institute For Autism, LLC/ABA Clinic Management, LLC.
2. I understand that I have the opportunity to ask questions before signing this document. I understand that an initial session will include an assessment to evaluate a child’s current skills prior to Learner Social Club Services. I understand that if the child has any challenging/maladaptive behaviors, ABA therapy services may be recommended.
3. Arizona Institute For Autism, LLC will discuss the discontinuation of services if a client fails to adhere to policies and procedures of Learner Social Club.
4. I understand that the case BCBA who is licensed by the Behavioral Analyst Board will complete an assessment of the client that will be used to develop program admittance into Learner Social Club. Assessment results will be shared if the parent/guardian would like a copy for record keeping. I understand that I reserve the right to withdraw my child at any time from the evaluation or/and treatment program.
5. I understand that the Assessment and Treatment procedures and outcomes are confidential. Release of information to third parties shall only occur upon obtaining a signed agreement from a client’s parents/legal guardians.
6. I understand that Arizona Institute For Autism, LLC/ABA Clinic Management, LLC  may release information without my prior consent if ordered by a court of law. I understand that I may contact Arizona Institute For Autism Clinical Director, Rula Diab at (480) 707-2195 to discuss program concerns.
7. I am also aware that providers are legally required to report suspected occurrences of child abuse or neglect or if I or my child present clear and present danger to ourselves or to others.
8. I understand that Arizona Institute For Autism, LLC/ABA Clinic Management, LLC  hires individuals with Bachelor’s or Master’s degrees supervised by BCBAs. All components of the program will be conducted under the supervision of a Board Certified Behavior Analyst. I understand that payment for services must be paid upon receipt of services invoice.
9. I understand that under the code of ethical conduct developed by the Behavior Analyst Board, Arizona Institute For Autism, LLC/ABA Clinic Management, LLC. staff and providers should maintain professional relationship and confidentiality for client’s information unless a consent form is obtained.
10. I understand that parents/legal guardians should give advance notification for cancellation 24 hours and parents should be present for sessions that are conducted in the home setting.
11. I understand that I can be contacted via Phone Text or Email to communicate with matters related to client and treatment implementation.
12. I understand that In the unlikely event of a behavioral crisis, weather or medical emergency, the Client's Learner Social Club supervisor can be called via cell phone as well as his parents. Parents will have the Learner Social Club supervisor’s phone number. Our agency has a policy to call 911 if necessary. Parents can also contact 911 or bring the member to the local emergency room in a medical or mental health emergency.

13. I hereby assign and request payment directly to Arizona Institute For Autism LLC/ ABA Clinic Management LLC of any program fees and release of any information required for consideration of payment for services.

The Arizona Institute for Autism, LLC/ ABA Clinic Management, LLC does not authorize staff  of the Learner Social Club to administer medication of any kind.

By signing below, I understand the Arizona Institute For Autism, LLC/ ABA Clinic Management LLC staff does not administer medication.

 

This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows your providers to obtain and release your protected health information to a person or organization that you authorize. You can revoke this authorization at any time by submitting a request in writing to the provider. Revoking this authorization will not affect any action taken prior to receipt of your written request to revoke.

I understand this release is voluntary and applies to all programs and services operated under Arizona Institute For Autism, LLC/ ABA Clinic Management, LLC.  I understand that I may revoke this authorization at any time by notifying Arizona Institute For Autism, LLC in writing but if I do, it will not have any effect on any taken before receipt of the revocation.

I, the undersigned, authorize Arizona Institute For Autism/ABA Clinic Management, LLC to release, exchange or request access to the information specified below for the below-named client. I hereby authorize Arizona Institute For Autism, LLC/ABA Clinic Management, LLC to exchange / release / obtain information both verbally and in writing.

Description of information to be exchanged / released / obtained:

• Education records
• Medical records 
• Evaluation/assessment/eligibility records 
• Clinical records (including behavior analytic, psychological, physical, occupational, and speech therapies)

Name of third party to exchange information

 

Parent/Guardian Participation: Parent/guardian understands that Arizona Institute For Autism, LLC/ ABA Clinic Management, LLC the program is a parent participation model. This means that the Parent/Guardian’s participation during the Learner Social Club is mandated if needed by Arizona Institute For Autism, LLC/ABA Clinic Management, LLC. The Learner Social Club Supervisor will review with the Parent/Guardian in detail the expectations for participation if needed by scheduled appointment only.

The Parent/Guardian agrees to participate in the program as requested by the Learner Social Club Supervisor if necessary or as mandated by the funding source.

I agree to allow Arizona Institute For Autism, LLC/ABA Clinic Management, LLC to contact me in the following methods regarding my Private Health Information (PHI), evaluation, and treatment.

Please review the following:

●  Home Phone
●  Cell Phone
●  Work Phone
●  Alternate Phone
●  Text Message
●  Email
●  Work-Related Purposes
●  Wifi

When contacting Arizona Institute For Autism, LLC. We will make every effort to respond within 24 hours (except for weekends and holidays). If you cannot reach Arizona Institute For Autism, LLC employees and are experiencing an emergency, call 911 or go to the nearest emergency room and ask for the psychiatrist on call.

In order to track your child’s progress more effectively, Arizona Institute For Autism, LLC/ABA Clinic Management will periodically videotape and/or photograph your child during an intervention. The specific purpose of the photographs and/or videos is to enable members of the clinical leadership at Arizona Institute For Autism, LLC/ABA Clinic Management, LLC including directors and clinical management, to review your child’s program, your child’s progress, our staff members’ performance, and to ensure that the quality of our program is constantly maintained and advanced.

Arizona Institute For Autism, LLC/ ABA Clinic Management LLC would appreciate your permission to include videos and/or photographs of your child for the following specific and limited purposes.

Please review the following:

●  Workshop presentations, training other professionals (i.e., school personnel, psychologists, regional center staff).
●  Presentation to parent groups/parent workshops.
●  Presentation of data at conferences.
●  Arizona Institute For Autism published manuals, book chapters, and/or research articles.
●  Arizona Institute For Autism in-house staff training.
●  Arizona Institute For Autism in-house parent training.
●  Arizona Institute For Autism promotional materials (brochures, videos, website, etc.).

By signing below, I give Arizona Institute For Autism/ABA Clinic Management, LLC permission to videotape and/or photograph my child for the purposes detailed above unless stated otherwise.

By signing below, I do not give Arizona Institute For Autism permission to videotape and/or photograph my child for the purposes detailed above unless stated otherwise.

Arizona Institute For Autism, LLC/ABA Clinic Management, LLC intends to foster relationships with consumers and their families that thrive on respect, professionalism, and care. Because of this, our desire is that open communication exists between the consumer/consumer’s family and the Arizona Institute For Autism’s team assigned to that consumer. Arizona Institute For Autism desires that families voice concerns with their assigned team as they arise. Assigned staff will make every attempt to validate and address concerns immediately. Should a consumer or their family encounter a situation in which they do not think their concern has been adequately addressed, they may follow the steps below to file a grievance with the agency:

Contact the assigned Case Supervisor/BCBA and voice their concern. If the Case Supervisor/BCBA is not able to adequately address the concern, continue as follows.Contact the Clinical Director, Rula Diab at (480) 707-2195 and voice their concern. Families should note that if the nature of the grievance is such that they would prefer to immediately contact the ClinicalManager (e.g. If the grievance involves an issue regarding the assigned Direct Interventionist, Case Supervisor, BCBA, etc.),their correspondence will be received and addressed as quickly as possible.

Your child will not be released to anyone who is not on this list, without prior written confirmation from you. By signing this form, I give the Arizona Institute for Autism staff permission to allow for pick-up/drop off of my child by the persons mentioned below.

Everyone on this list must present an ID at the time of pick up.

Please note that parent/guardian names must be included for drop-off, pick-up, and client signature.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU OR YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Arizona Institute For Autism, LLC/ABA Clinic Management, LLC is dedicated to maintaining the privacy of our client’s (the Client”) individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding the Client and the treatment and services we provide. We are required by law to maintain the confidentiality of health information that identifies Clients. We also are required by law to provide this notice of our legal duties and the privacy practices that we maintain in our practice concerning Client’s PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

●  How we may use and disclose a Client’s PHI,
●  Privacy rights in PHI,
●  Our obligations concerning the use and disclosure of PHI.

The terms of this notice apply to all records containing a Client’s PHI that are created or retained by Arizona Institute For Autism, LLC, ABA Clinic AManagement, LLC. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all records created or maintained in the past, and for any records that we may create or maintain in the future. Arizona Institute For Autism/ABA Clinic Management will always post a copy of our current Notice in our offices in a visible location, and you may request a copy of our most current Notice at any time.

I. HOW Arizona Institute For Autism/ ABA Clinic Management WILL USE AND DISCLOSE PHI.

Arizona Institute For Autism Behavioral Services Inc. will use and disclose a Client’s PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of our uses and disclosures, with some examples.

A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Prior Written Consent.

Arizona Institute For Autism may use and disclose a Client’s PHI without consent for the following reasons: 1. For treatment. Arizona Institute For Autism may disclose PHI to physicians,

psychiatrists, psychologists, behavior interventionists, and other licensed healthcare providers who provide a Client with health care services or are otherwise involved in his or her care. Example: If a psychiatrist is treating a client, Arizona Institute For Autism may disclose PHI to her/him in order to coordinate services.

2. For health care operations. Arizona Institute For Autism may disclose PHI to facilitate

the efficient and correct operation of the services it provides. Examples: Quality control – Arizona Institute For Autism might use PHI in the evaluation of the quality of services that a Client receives or to evaluate the performance of the behavior interventionists who provided these services. Arizona Institute For Autism may also provide PHI to company attorneys, accountants, consultants, and others to make sure that Arizona Institute For Autism follows applicable laws.

3. To obtain payment for treatment. Arizona Institute For Autism may use and disclose PHI to bill and collect payment for the treatment and services Arizona Institute For Autism has provided. Example: We might send PHI to the Client’s Regional Center or insurance company in order to get payment for the services that Arizona Institute For Autism has provided. Arizona Institute For Autism could also provide PHI to business associates that provide services for Arizona Institute For Autism.

4. Other disclosures. Examples: Consent isn’t required if a Client needs emergency

treatment if Arizona Institute For Autism attempts to get consent after treatment is rendered. If Arizona Institute For Autism tries to get consent, however, you are unable to communicate with us, but Arizona Institute For Autism thinks that you would consent to such treatment if you could, Arizona Institute For Autism may disclose PHI.

B. Certain Other Uses and Disclosures Do Not Require Consent. Arizona Institute For Autism may use and/or disclose PHI without consent or authorization for the following reasons:

1. Required by Law. When disclosure is (a) required by federal, state, or local law; judicial, board, or administrative proceedings; or law enforcement; (b) compelled by a party to a proceeding before a court, arbitration panel or an administrative agency pursuant to its lawful authority; (c) required a search warrant lawfully issued to a government law enforcement agency; or (d) compelled by the patient or the patient’s representative pursuant to Arizona Health and Safety Codes or to corresponding federal statutes of regulations, such as the Privacy Rule that requires this Notice.

2. To avoid harm. When disclosure: (a) to law enforcement personnel or persons may be able to prevent or mitigate a serious threat to the health or safety of a person or the public; (b) is compelled or permitted by the fact that the Client is in such mental or emotional condition as to be dangerous to him or herself or the person or property of others, and if Arizona Institute For Autism determines that disclosure is necessary to prevent the threatened danger; (c) is mandated by the Arizona Child Abuse and Neglect Reporting law (for example, if we have a reasonable suspicion of child abuse or neglect); (d) is mandated by the Arizona Elder/Dependent Adult Abuse Reporting law (for example, if we have a reasonable suspicion of elder abuse or dependent adult abuse); and (e) if disclosure is compelled or permitted by the fact that you or your child tells us of a serious/imminent threat of physical violence against a reasonably identifiable victim or victims.

3. For public health activities. When disclosure is for: (a) maintaining vital records, such as births and deaths; (b)preventing or controlling disease, injury or disability, (c) notifying a person regarding potential exposure to a communicable disease; (d) notifying a person regarding a potential risk for spreading or contracting a disease or condition; (d) reporting reactions to drugs or problems with products or devices; or (e) notifying individuals if a product or device they may be using has been recalled.

4. For health oversight activities. Arizona Institute For Autism may disclose PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example: investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health care system in general.

5. For specific government functions. Examples: Arizona Institute For Autism may disclose PHI of military personnel and veterans under certain circumstances.

6. For Workers’ Compensation purposes. Arizona Institute For Autism may provide PHI in order to comply with Workers’ Compensation laws.

7. Appointment reminders and health-related benefits or services. Arizona Institute For Autism permitted to contact you, without prior authorization, to provide an appointment reminders or information about alternatives or other health-related benefits and services that may be of interest.

C. Certain Uses and Disclosures Require You to Have the Opportunity to Object. 1. Disclosures to family, friends or others. Arizona Institute For Autism may provide PHI
to a family member, friend, or another individual who you indicate as involved in the Client’s care or responsible for the payment of health care, unless you object in whole or in part. Retroactive consent may be obtained in emergency situations.

D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in Sections I.A, I.B, and I.C above, Arizona Institute For Autism will

request written authorization before using or disclosing any of the PHI. Even if you have signed an authorization to disclose PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures (if Arizona Institute For Autism has not taken any action subsequent to the original authorization) of PHI by Arizona Institute For Autism.

II. RIGHTS REGARDING PHI
These are your rights with respect to PHI:

A. The Right to See and Get Copies of PHI. In general, you have the right to see PHI that is in Arizona Institute For Autism possession, or to get copies of it; however, you must request it in writing. If Arizona Institute For Autism does not have the PHI, but Arizona Institute For Autism knows who does, Arizona Institute For Autism will advise you how you can get it. You will receive a response from Arizona Institute For Autism within 30 days of receipt of your written request. Under certain circumstances, Arizona Institute For Autism may deny your request, but Arizona Institute For Autism will give you, in writing, the reasons for the denial. Arizona Institute For Autism will also explain your right to have the denial reviewed. Arizona Institute For Autism may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.

B. The Right to Request Limits on Uses and Disclosures of PHI. You have the right to ask that Arizona Institute For Autism limits how it uses and discloses PHI. While Arizona Institute For Autism will consider your request, Arizona Institute For Autism is not legally bound to agree. If Arizona Institute For Autism does agree to your request, Arizona Institute For Autism will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that Arizona Institute For Autism is legally required or permitted to make.

Private Pay

Please review the following:

I understand that it is my responsibility to pay for Learner Social Club services.
I understand that my credit card on file will be run manually at the Arizona Institute for Autism, LLC based on the monthly fee schedule.
I understand that an initial complimentary assessment is required for all learners in the Learner Social Club.
Splitting Fee Cost among Caregivers

The Arizona Institute for Autism is not responsible for invoicing or billing more than one parent or guardian. It is the parents/guardian’s responsibility to ensure full payment is provided and personally ensure that accurate percentages are contributed by the other caregivers as they have agreed upon. The individual that signs this agreement will be considered the responsible party from whom payment will be required in full.

Payment Plans

Payments plans may be considered and offered on a case-by-case basis, however, all payment plans require a separate contractual agreement. Payment plans are only approved on occasion due to extenuating circumstances  and provided as a courtesy. Payment plans may be not considered for outstanding balances already accrued. Payment plans require a credit card on file and will be charged a minimum amount on a specified date until the balance is paid in full. If timelines and contractual agreements are not abided by, the agreement will be immediately considered null and void, defaulting to immediate payment of the entire balance.

In the event a client terminates and/or is discharged from the Learner Social Club Program, the payment plan is terminated, and the entire balance is required to be paid in full within one (1) week of the client’s last day. Furthermore, if payment is not received by the agreed due date, services will be put on hold until the agreed amount or payment is received in full.

Delinquent Accounts

Please review the following:

I understand failure to comply with this financial agreement and declining agreement and declining to work with the Arizona Institute for Autism in good faith to resolve the problem will result in a termination of services.  
Accounts past due ninety (90) days or more are subject to collection and any additional associated fees.

It is important that you read the Learner Social Club Financial Agreement carefully, as your signature on this document indicates you have read, understand, and agree to the Financial Policies below. Please ensure that you have reviewed all terms in addition to the Learner Social Club Agreement and Cancellation Policy.

I understand that my payment information is verified by the ABA Billing Specialist. Our office policy is that full payment, as well as, account balances are due at the time of service. This agreement is necessary for your child to participate in the Learner Social Club. 

It is your responsibility to follow-up with an ABA Billing Specialist to ensure your account is paid within 60 days of the date of service. We must emphasize that as health care providers, our relationship is with you, our client. You are responsible for knowing what your program payments are on a monthly basis. If you are unsure, please contact your ABA Billing Specialist. The office assumes no responsibility for your lack of knowledge regarding your program fees. 

General Information

Our Learner Social Club program takes an integrative approach and currently serves the following age groups:​​

AIA Youth Learners 4-17 years old 

*All learners must be potty trained for the Learner Social Club program

Payment Information

• I understand that all children are affiliated with the Arizona Institute for Autism. Learner Social Club membership is billed monthly on the 1st of each month
• I understand that all children must sign up and adhere to a 3-month minimum agreement.
• Program fees are paid by the calendar month. Program fees are due by the 1st of the month and are considered late if received after the due date. We highly encourage you to plan ahead and make payments before the end of the month or on the last day of your class. A late fee of $75.00 will be added after the 1st to all past due accounts.
• Program membership fees are non-refundable and non-transferable.
• Delinquency in payment will prohibit your child’s ability to attend the program. Delinquent accounts will be reviewed and may be referred to a collection agency.
• A $75.00 late service charge will be collected for all returned checks.
• You have the option to pay online for your program fees/tuition. A convenience fee will apply to all online payments.
• NO deductions in program fees or pro-rating will be made for holidays, vacations, absences, or missed days. For missed days, make-ups are not available. 
• There are no private sessions for the Learner Social Club.

Discounts

Sibling
I understand that a sibling discount of $50 off can be applied for the first sibling discount. Second sibling discount $25. Maximum of $75 off during registration. One time use only. 

Military & First Responder Discount

$15 off during registration.One time use only. 

Bring a Friend Information

On the last Friday of each month, the Arizona Institute for Autism will allow each child to bring a friend. Schedule may be subject to change due to the holidays and upcoming events. On Bring a friend days, the Arizona Institute for Autism will host a special movie for all friends and learners to enjoy. All friends must sign an Arizona Institute for Autism waiver. Limited capacity will be available for Bring a Friend day!

Cancellation

I understand that I must notify billing at billing@abaclinicaz.com to cancel or pause service. Please allow a 30 day notice to cancel or pause service.

Drop Off Information

• I understand that children that are dropped off for the Learner Social Club are encouraged to stay inside the Arizona Institute for Autism until they are picked up.
• I understand that children must have a snack and water provided at all times.
• I understand that children must be potty trained for the Learner Social Club program.
• I understand ​​children misbehaving or disrupting Learner Social Club may be asked to sit out for part of the session. If behavior continues your child may be sent to the front office and you will be called to come and pick them up.
  I understand that children should always attend sessions wearing casual clothes for the proper attire.
• I understand that If my account is not paid in full within 90 days, I understand that it will be considered delinquent. No additional appointments will be made for clients with delinquent accounts until they are current. Delinquent accounts will be turned over to a licensed collection agency; I agree to pay a collection fee equal to 30% of our outstanding balance at the time the account is placed with the collection agency.
• I understand that a 2.5% transaction fee will be added to my monthly invoice if funds are being paid by ESA (Empowerment Scholarship Account).               

Fee Schedule

The following fees are assessed for cancellations and no-shows: 

• Cancellation Fees: $50.00 per session
  No-Shows: $50.00 per hour, per session                                             

Learner Social Club Cancellation

At the Arizona Institute for Autism (AIA), our goal is to provide quality Learner Social Club care to all of our clients in a timely manner. No-shows, late arrivals, and cancellations inconvenience not only our providers but our other clients as well. Please be aware of our policy regarding missed and late sessions.

When a program is booked, you are holding space on our schedule that is no longer available to our other clients. In order to be respectful of your fellow clients, please call the front desk or contact the Learner Social Club Supervisor as soon as you know you will not be able to make your appointment.

If cancellation is necessary, we require that you call at least 72 hours in advance. Learner Social Club is in high demand, and your advanced notice will allow another client access to that appointment time. Failure to cancel within 72 hours will result in a fee of $50.00.

How to Cancel 

If you need to cancel for a Learner Social Club, please call or email us between the hours of 8:00 AM-6:00 PM. If necessary, you may leave a detailed voicemail message. We will return your call as soon as possible.

Late Cancellations/No-Shows

A late cancellation is considered "late" when you arrive 15 minutes after your scheduled session. A no-show is when a client misses a day without canceling. In that case, we will charge a client a fee of $50.00/hour for any missed program session.

The following stations apply to the Learner Social Club. Schedules may be subject to change.

*Below is the Learner Social Club schedule. Schedule may be to subject to change

4:00-4:15 Arrival
4:15-4:30 Learner Social Club Rules Expectations & Introductions
4:30-4:45 Learner Social Club Station Rotation
4:45-5:00 Snack & Break
5:00-5:15 Learner Social Club Station Rotation
5:15-5:30 Learner Social Club Station Rotation
5:30-5:45 Learner Social Learner Recap PLUS show & Tell
5:45-6:00 Pick-Up

Private Pay

Please review the following:

I understand that it is my responsibility to pay for Learner Social Club services.
I understand that my credit card on file will be run manually at the Arizona Institute for Autism, LLC based on the monthly fee schedule.
I understand that an initial complimentary assessment is required for all learners in the Learner Social Club.

 

Splitting Fee Cost among Caregivers

The Arizona Institute for Autism is not responsible for invoicing or billing more than one parent or guardian. It is the parents/guardian’s responsibility to ensure full payment is provided and personally ensure that accurate percentages are contributed by the other caregivers as they have agreed upon. The individual that signs this agreement will be considered the responsible party from whom payment will be required in full.

Payment Plans

Payments plans may be considered and offered on a case-by-case basis, however, all payment plans require a separate contractual agreement. Payment plans are only approved on occasion due to extenuating circumstances and provided as a courtesy. Payment plans may be not considered for outstanding balances already accrued. Payment plans require a credit card on file and will be charged a minimum amount on a specified date until the balance is paid in full. If timelines and contractual agreements are not abided by, the agreement will be immediately considered null and void, defaulting to immediate payment of the entire balance.

In the event a client terminates and/or is discharged from ABA therapy, the payment, the payment plan is terminated, and the entire balance is required to be paid in full within one (1) week of the client’s last appointment. Furthermore, if payment is not received by the agreed due date, services will be put on hold until the agreed amount or payment is received in full.

Delinquent Accounts

Please review the following:
●  I understand failure to comply with this financial agreement and declining agreement and declining to work with the Arizona Institute for Autism in good faith to resolve the problem will result in a termination of services.
●  Deductibles, co-insurance, and co-pays are required to be paid on the day services are rendered. If payment cannot be made within three (3) business days of rendered services, follow-up and recurring appointments will be canceled until payment can be made. Failure to pay the balance after fifteen (15) business days will result in the termination of services.

Accounts past due ninety (90) days or more are subject to collection and any additional associated fees.

Credit Card on File

Please review the following:

●  I understand that a credit card must be put on file with authorization charges to be made. We accept Visa, Mastercard, Discover, or American Express.
●  I understand bypassing the credit card on files requirement cannot be waived.
●  I understand billing charges (i.e., services rendered, deductibles, co-pays, co-insurance) will be charged within 24 hours

of my appointment time.
●  I understand if I choose to place a debit/HSA/flex card on file as a primary form of payment, a secondary true credit card

must be put on file as a secondary form of payment in the event your debit/HSA/Flex card does not have sufficient funds.
●  I understand it is my responsibility to update credit card information. In the event, your primary and secondary card is declined, you will be contacted by phone and/or email to obtain active information. New information must be updated

within three (3) business days. If information is not obtained within three (3) business days, follow up appointments will be scheduled until this information is obtained and/or recurring appointments already scheduled will be canceled. If multiple attempts have been made to obtain payments and if the balance remains unpaid after fifteen (15) business days, services will be terminated.

Statements

Please review the following:
●  I understand that statements will be sent by request only.
●  I understand that by request only, yearly statements must be requested 30-45 business days ahead of time. Due to EOB/Insurance processing, yearly statements take 30-45 business days to generate and may not be complete if the Arizona Institute for Autism, LLC has not received EOBs.

By signing the financial agreement in the client intake packet, I authorize the Arizona Institute for Autism, LLC to charge my credit card provided herein. I agree to pay for services and understand the terms outlined in the financial agreement and financial consultation.