BCBA Attestation Form

BCBA ATTESTATION FORM AND SERVICES AGREEMENT

Client Name:   Client ID:

Service Location:

Parties

Service Provider (BCBA):

Certification Number:   State of Certification:   License Number (if applicable):

WHEREAS

WHEREAS, Service Provider is duly certified as a Board Certified Behavior Analyst and holds the credentials represented above, and maintains professional competence to deliver applied behavior analysis services in accordance with professional standards and applicable regulatory requirements; and

WHEREAS, Client desires to retain Service Provider to provide assessment, program design, supervision, and related BCBA services for the Client named herein, and Service Provider agrees to provide such services subject to the terms and conditions set forth in this Agreement; and

WHEREAS, Service Provider must attest to the truthfulness of records, compliance with ethical and certification requirements, and maintenance of documentation necessary for clinical and billing purposes.

Scope of Work

Payment Terms

Fee per unit/session or hourly rate: $

Billing schedule:   Payment due within days of invoice.

Late fee: assessed on overdue balances.

Client is responsible for any collection costs, reasonable attorney fees, and costs of enforcement associated with past-due payments.

Term and Termination

Agreement Start Date:   Agreement End Date:

Either party may terminate this Agreement for any reason by providing written notice to the other party not less than days prior to the effective termination date. Termination shall not relieve Client of payment for services already rendered or for reasonable wind-down activities.

Confidentiality and Records

Service Provider will maintain and protect confidential client information and clinical records in accordance with applicable professional standards and law. Service Provider will only disclose client records with written consent of Client or as required by law. All clinical notes, assessment reports, treatment plans, and supervision documentation created by Service Provider are the property of the record holder as determined by applicable law and the parties' agreement.

Records retention: from date of last service, unless otherwise required by law.

BCBA Attestation and Certifications

By checking each box and signing below, Service Provider certifies and attests to the truth and accuracy of the following statements under penalty of professional discipline and other remedies permitted by law:

I certify that I hold current BCBA certification as represented above and that my certification is not under suspension or revocation.

I attest that services provided will be in compliance with applicable ethical standards, professional practice requirements, and relevant laws governing behavior analytic services.

I attest that the records, supervision logs, and billing documentation submitted under this Agreement are true, accurate, and complete to the best of my knowledge.

If providing supervision, I attest that supervision hours meet applicable certification standards and that supervisee records will be maintained.

Compliance, Indemnity, and Limitations

Client agrees to cooperate with Service Provider and to provide information necessary for service delivery. Client will indemnify and hold Service Provider harmless from claims arising from Client's failure to provide accurate information or to follow professional recommendations, except to the extent caused by Service Provider's gross negligence or willful misconduct.

Service Provider's liability for any claim arising under this Agreement shall be limited to direct damages not to exceed the total fees paid by Client to Service Provider under this Agreement for the six months preceding the claim. Neither party shall be liable for consequential, incidental, or punitive damages except in cases of willful misconduct or as required by law.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the state selected by the parties: , without regard to conflict of law principles.

Entire Agreement

This document constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior agreements, representations, and understandings, whether written or oral. Any amendment must be in writing and signed by both parties.

Acknowledgment and Certification

By signing below, each signatory certifies under penalty of professional discipline and civil liability that they are authorized to execute this Agreement, that the information provided in this form is true and complete, and that they will comply with the terms set forth herein.

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