Food/Diet & Hygiene
Communication, Behavioral & Safety
Statement of Authority to Consent: I certify that I have the authority to represent the above-named client. I legally consent to assessment, release of information, and all legal issues regarding the above named client. Upon request, I will provide Play ABA with proper legal documentation to support this claim. I further hereby agree that if my status as legal guardian should change, I will immediately inform Play ABA of this change in status and will further immediately inform Play ABA of the name, address, and phone number of the person or persons who have assumed guardianship of the above-named client.
Permission for Assessment: I consent to allow the above-named client to participate in assessments including but not limited to behavioral assessment, educational assessment, and/or speech/language assessment given by a Play ABA employee to provide observations, interviews with members of the therapy team whom I give authorization to release information, interviews, observations or direct test/interview results with the above-named client.
Treatment Consent: I consent for treatment included but not limited to behavioral treatment, educational treatment, speech/language treatment to be provided for the above-named client through Play ABA, Play ABA employees, and contracted employees. I understand that the procedures used will consist of manipulating antecedents and consequences to produce improvements in behavior. At the beginning of the treatment, behavior may get worse in the environment where treatment is provided or in other settings. As part of treatment, physical prompting and manual guidance may be used. The actual treatment protocols that will be used have been explained to me by Play ABA staff. I authorize and request the implementation of the treatment procedures. I understand there is an expectation that the above-named client will benefit from this plan, but there is no guarantee that this will occur.
I understand that I may revoke this consent at anytime without penalty and I understand that there is no penalty for refusing to grant this consent. However, I cannot revoke consent for action that has already been taken. A copy of this consent shall be valid as the original. I understand that I have a right to receive a copy of this authorization upon request. I understand what this agreement means.
Information regarding Play ABA clients, obtained during service provision, is considered private and confidential. However, there are conditions in which this information will be shared with outside agencies/entities.
reimbursement for Deparment of Economic Services/Division of Developmental Disabilities (DES/DDD) services requires disclosure of client information and detailed reports regarding service dates, times, activities, and progress. Unusual incidents and or events that potentially threaten the health or well-being of the client or any minor on the premises must be reported not only to DES/DDD but to appropriate law enforcement agencies.
Play ABA is required to disclose protected health information to the individual (or their personal representatives) at their request and to outside agencies for other reasons covered by law or national security including public health activities, serious threats to health or safety, essential government functions, and/or Worker's Compensation claims.
Client requests must be made by the client or their legal representative in writing to Play ABA for release of information to outside agencies.
Play ABA will use electronic communication and transmission for the purposes of billing, updates on client speciic information, and changes in service eligibility. Individuals or their legal representative may request an alternate method of communication if they so desire.
Individuals or their legal representative who feels their right to privacy has been violated may file a grievance with Play ABA describing the incident and disclosure. Play ABA will respond to all grievances within 10 business days.
Play ABA will continually recruit, train, monitor and refer individuals qualified to provide DDD services.Play ABA will collect, maintain, and provide written summaries of monthly billing statements and progress reports.Play ABA will, at its discretion, provide employee training for medication administration and transportation. Play ABA employees may not administer medications or provide transportation without prior approval of Play ABA.Play ABA will, within guidelines of DDD, work with the treatment team to establish an individualized program focusing on the unique needs of the service recipient based on the type of service received. Play ABA may, for any or no reason, remove, suspend, or discontinue employment of any service provider. In case an emergency arises, I will contact the Play ABA emergency pager line at (602) 356-0298.I (Client) may refer individuals for employment at Play ABA. However, Play ABA has final authority in all decisions related to hiring, status, and pay rates of its employee.I (Client) am required to interview and orient all potential service providers who will be working in my home or with the service recipient. I understand that I may, for any or no reason, contact Play ABA to refuse services from any employee.I must, as soon as possible, communicate any concerns regarding service delivery, program goals/objectives and employee behaviors/actions to Play ABA.I (Client) may file a written grievance with the Play ABA Client Service Representative regarding any issue and expect a written response within ten working days.I (Client) understand that Play ABA employees are not permitted to bill Play ABA for Habilitation and/or Respite services over the amount of hours allotted by DDD or outside of the authorization period.I (Client) must provide any and all training materials, reinforcers, and other items required for special diets or safety concerns. I (Client) must review and verify the accuracy of all time sheets and data sheets submitted to Play ABA.I (Client) must thoroughly train all new providers on the special needs of the service recipient and update all providers of changes in the daily routine or needs of the service recipient.I (Client) may not offer providers additional compensation for DDD services, including reimbursement for transportation. I also understand that Play ABA may not request or expect additional compensastion for the provision of DDD services and that any such requests should be documented in a formal grievance and submitted to the Play ABA Client Services Representative.I (Client) have been given a copy of the Play ABA Privacy Statement and I understand the contents of that statement.By signing this document I certify that I am the responsible party for the individual receiving services. I understand that the agency will supply this document and the ISP goals (if habilitation services are indicated) to the Provider.
This consent form is to authorize the release of the following information to Play ABA, regarding my child. This release includes all employees and individuals who provide services on a contract basis to Play ABA (i.e. contracted speech therapists, behavior analysts, occupational therapists, music therapists, etc). Permission is also given for the above-named party to discuss issues related to this case with Play ABA, employees and contractors (both parties may disclose and receive information regarding the case).
Consent to Bill Insurance Agreement
My signature below indicates that:
I give permission for Play ABA and/or an individual provider of Play ABA to bill the insurance company for covered services, and to the exchange of information necessary to secure payment for services. Information may include my child's diagnosis, services dates, types of services, and other information necessary to process the claim.
I understand that if an insurance payment is made directly to me for Play ABA services, I am responsible for immediately sending such payments to Play ABA.
I will notify Play ABA of any changes to my child's health insurance coverage, as well as any denial information.
I understand that I am financially responsible for any insurance co-pays or co-insurance.
I understand that I am responsible for services provided that are not covered by insurance.
I am the individual holding authority to authorize insurance payments.