Healthcare BCBACenter Form

Healthcare BCBACenter Form

Patient Information

Date of Birth:

Gender: Male Female Non-binary Prefer not to say

Emergency Contact

Insurance Information

Medical & Developmental History

Seizure Disorder: Yes No

Consent for Services and Acknowledgements

I authorize BCBACenter clinicians to provide assessment, treatment, and related services consistent with applied behavior analysis (ABA). I understand that services may include behavioral assessment, direct therapy, parent/caregiver training, data collection, and periodic re-evaluation. I understand the nature, purpose, anticipated benefits, and commonly associated risks of recommended services.

I acknowledge that I have the right to ask questions, to refuse or withdraw consent at any time without jeopardizing future access to services from the provider, except as otherwise required by law. Withdrawal of consent for specific interventions must be provided in writing and may require coordination of a transition plan.

Confidentiality and limits: Clinical records are confidential but may be disclosed without consent when required by law, including but not limited to suspected abuse or neglect, threats of harm to self or others, or by court order. Information relevant to treatment coordination may be shared with other providers or insurers as necessary for care or payment, subject to applicable privacy protections.

Recording and Observation: I consent to clinical observation by students, trainees, or other staff when required for supervision or training, unless I decline. I consent / do not consent to audio or video recording of sessions for clinical purposes (select preference below).

Consent to recording Do not consent to recording

Telehealth: I consent to telehealth services when recommended. I understand telehealth has distinct benefits and risks, including limitations related to technology, privacy, and the inability to provide certain hands-on interventions.

Billing, Assignment of Benefits, and Financial Responsibility

I authorize BCBACenter to submit claims to my insurer and assign benefits payable for services to the provider where permitted. I acknowledge responsibility for co-payments, deductibles, co-insurance, and services not covered or denied by insurance. I agree to provide accurate insurance information and to notify the provider of changes.

Cancellation and missed appointments: The provider's cancellation policy applies; excessive late cancellations or no-shows may result in discharge or termination of services.

Release of Information / HIPAA Authorization

I authorize the release and exchange of protected health information necessary for treatment, payment, and healthcare operations to and from BCBACenter, my insurance carrier, and the providers or agencies listed below. This authorization includes clinical summaries, diagnostic information, assessment reports, treatment plans, and relevant billing information.

Purpose of disclosure: Coordination of care, payment of claims, care planning, educational planning, and other treatment-related activities. I understand that I may revoke this authorization at any time in writing except to the extent that actions have already been taken in reliance on it.

Patient Rights Acknowledgment

I acknowledge that I have received or been offered a copy of the practice's privacy notice setting forth my rights under applicable privacy laws. I understand my rights to inspect my records, request amendments, and obtain an accounting of disclosures as permitted by law. I understand that complaints about privacy practices may be submitted to the provider's clinic administration.

By signing below I certify that the information I have provided is accurate to the best of my knowledge and that I consent to the provision of services and release of information as outlined above.

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