Healthcare ABA Consent Release

HEALTHCARE ABA CONSENT RELEASE

Client Name:    Date of Birth:

Patient / Guardian Information

Insurance / Billing

Medical / Behavioral History

Description of ABA Services

Purpose:

Service Location: Home School Clinic Telehealth

Consent to Evaluation and Treatment

I hereby authorize the provider and designated staff to perform an assessment and to provide Applied Behavior Analysis (ABA) services as described above. ABA services may include functional assessment, development of behavior intervention plans, implementation of teaching procedures, data collection, modification of antecedents and consequences, systematic prompting, fading, shaping, reinforcement procedures, and non-invasive behavior management strategies. I understand that less-common procedures may include brief physical guidance for safety or task completion; such procedures will be used only when clinically indicated, in accordance with professional standards, and with the least intrusive means necessary.

I understand that reasonable efforts will be made to explain treatments and that I may refuse any specific intervention at any time. I understand that refusal may affect treatment outcome and coordination with other providers. I have had the opportunity to ask questions about the nature, purpose, risks, benefits, and alternatives to ABA treatment and have received satisfactory answers.

Risks, Benefits & Alternatives

Benefits may include reduction in problematic behaviors, acquisition of new skills, and improved adaptive functioning. Potential risks include transient increases in targeted behaviors, emotional discomfort, fatigue, or frustration. Alternatives to ABA include other therapeutic approaches, educational interventions, or no treatment. These have been discussed with me to the extent applicable.

Release of Information / Authorization

I authorize the release and exchange of clinical information and records as necessary to provide, coordinate, or secure payment for ABA services. This authorization includes sharing with physicians, schools, case managers, insurance payors, other providers, and agencies involved in the client's care.

Assessment reports
Treatment plans/behavior intervention plans
Progress notes
Billing and payment information
Video/audio recordings

This authorization is valid until: . I understand I may revoke this authorization at any time in writing, except to the extent that the provider has already acted in reliance upon it. A revocation will not affect disclosures made prior to receipt of the written revocation.

Recording & Observations

I consent to allow staff to observe sessions for supervision or training purposes under conditions that protect confidentiality: Yes No

I consent to video/audio recording of sessions for clinical, supervisory, or training purposes: Yes No

HIPAA / Privacy Acknowledgment

By signing below, I acknowledge that I have received or been offered the provider's Notice of Privacy Practices describing how protected health information may be used and disclosed and how I may access this information. I authorize the use and disclosure of my protected health information as described in this document and in the authorizations above.

I understand that I am financially responsible for charges not paid by insurance, including copayments, deductibles, non-covered services, and services denied for lack of authorization. I authorize release of information necessary to process claims and assign benefits to the provider as applicable.

Emergency Treatment

In the event of an emergency during a session, I authorize staff to secure emergency medical treatment and to disclose pertinent health information to emergency responders and receiving facilities as necessary. I consent to emergency treatment: Yes No

Acknowledgment & Certification

I certify that the information on this form is accurate to the best of my knowledge. I understand that by signing I consent to the services described and to the release of information as authorized above. I further understand that I may withdraw consent in writing at any time, except where disclosures have already been made in reliance on this authorization.

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