ASOFL Intake Packet

Please fill out the following forms

CLIENT INFORMATION

Client's Full Name

First Last

Client's Date of Birth

Parent/Guardian Name

First Last

Address

Street Address City State ZIP Code

Home Phone Number

Cell Phone Number

Parent Email Address

2nd. Parent Email Address

Child's School

Pediatrician

Pediatrician Phone

Insurance Name

Insured’s Name

Insured’s Date of Birth

Insurance Member/Group Number

Insurance Benefits/Eligibility Contact #

Emergency Contact(s)

Emergency Contact Phone

Allergies

Special Diet

Notes

Section - Notice of Health Information Privacy Practices

Notice of Health Information Privacy Practices

This notice describes how health information may be used and disclosed by Autism Services of Florida. We also describe your rights and certain obligations we have regarding the use and disclosure of your health information. Autism Services of Florida must interact with other providers and outside entities in order to provide services.

Your Rights Regarding Health Care Information About You:

Right to inspect and obtain a copy of your medical record.
Right to amend your record. If you feel your information is incorrect or incomplete, you may ask us to amend the information.
Right to an accounting of disclosures. You have the right to request a list of your health information that has been given to someone outside of Autism Services of Florida.
Right to request restrictions. You have the right to request a restriction or limitation on the information we may use or disclose. We will accept your request unless the information is needed to provide treatment.
Right to request confidential communication or to receive your information in a different way. You may request that we communicate with you in a different way or location. We will try and honor your request if the request is something we are able to offer to all patients equally.
Right to a paper copy of this notice- You have a right to a copy of this notice and may ask for a copy at any time. To obtain a copy, contact Autism Services of Florida at (239) 349-3139.

We are required by law to:

Keep your health information private.
Give you this notice, which describes your health information privacy rights and our duty to maintain your privacy.
Follow the terms of this notice while it is in effect.
Only use or disclose your health information with authorization except as provided in this notice.

How We May Use and Disclose Protected Health Care Information: Autism Services of Florida may use and disclose your health information without your permission in some of the following ways.

Treatment purposes-This information would be used to provide treatment or services or assist other providers with your treatment.
Payment purposes-Treatment and services you receive may be billed and payment may be collected by an outside agency (i.e., an insurance company).
Operations purposes- In order to run our business, your information may be used for quality management, receiving accreditation, certification, and licensing, or for auditing, medical review, or legal services.
Individuals involved in your care-This may include leaving messages at your residence related to appointments and treatment reminders.
Requirements by federal, state, or local law.
Public Health Risks-This relates to preventing or controlling neglect, abuse, disease, or injury.
Health Oversight Activities- The information could be used to ensure we follow healthcare laws and regulations related to oversight and licensure.
Lawsuits or Legal Activities-This relates to a lawsuit you may be involved in or other similar proceedings or under a subpoena or court order.
Law Enforcement Disclosure-As required by state or federal law and as required in response to a court order or subpoena, your information may be released.
Research- All research projects are subject to a special approval process, which evaluates a proposed research project and its use of information, balancing the research needs with the patient’s need for privacy. Before we use or disclose information for research, the project will have been approved and we will ask your permission to use your information to participate in the research project.
Serious threat to health and safety-We may give your information to prevent a serious threat to your health and safety or the health and safety of the public or another person. In an emergency, we may contact your family or persons responsible for your care.
Business Associates- We may be required to contract with outside providers for services to run our business (i.e., computer company, billing specialist, other behavior analysts). By contract, we require our business associates to safeguard your information.

Other Disclosures:

All other uses and disclosures not covered by this notice or the laws applied to us will be made only with your written authorization or the authorization of a designated person as allowed by state or federal law. You may revoke that authorization in writing at any time.

Changes to the Notice:

We reserve the right to change our notice at any time. We will make a copy of the new notice available to you.

Acknowledgement of Receipt of the Rights of the Client

I hereby acknowledge that I have received Rights of the Client: Information for Clients & Parents/Guardians/Custodians and that the client's rights have been clearly outlined.

(You may request a review and/or explanation of the client's rights with the owner of Autism Services of Florida at any time.)

Guardian/Parent/Custodian Print Name

Date

Guardian/Parent/Custodian Signature

Date

Administrator Print Name & Title

Date

Administrator Sign Name & Title

Date

Complaints & Grievances Related to Privacy

HIPAA Complaint Procedure

The Health Insurance Portability and Accountability Act (HIPAA) requires healthcare providers to provide a process for clients to make complaints concerning violations of the privacy of protected health information. Autism Services of Florida ensures that clients/guardians have a process to file complaints involving the privacy of information.

A client/guardian may file a complaint or grievance with Autism Services of Florida. We will work towards a resolution through the following process:

If a client/guardian wishes to make a complaint or grievance regarding privacy practices, the staff member will request that the client put the complaint in writing to the owner. The complaint/grievance will be addressed in accordance with our policy.

Autism Services of Florida will complete the complaint/grievance process within 30 days of receipt of the written complaint by the client/guardian.

Autism Services of Florida will keep all documents related to the client/guardian's complaint/grievance and resolution in a file separate from the health information record in a secure location. Autism Services of Florida's goal is to hear, review, and address complaints/grievances to ensure a mutually satisfactory client–clinic/guardian relationship. We will not subject a person filing the complaint/grievance to negative or retaliatory treatment.

Or, you may also address a complaint to:

Office of Civil Rights, Medical Privacy Complaint Division,

US Dept. of Health and Human Services,

200 Independence Ave, SW, Washington, D.C. 20201

or call 1-866-624-7748

Acknowledgement of Receipt of Health Information Privacy Practices & Complaints and Grievances

Client/guardian Acknowledgment

I acknowledge that I have received the Notice of Health Information Privacy Practices stating how my information may be used or disclosed by Autism Services of Florida and have been given the opportunity to ask questions regarding the notice.

Print Client Name

Parent/Guardian Signature

Date

Photo and Video Consent

Photos/Videos may be used for training staff, social media, educational purposes, and assessing client progress. I understand that at any time I can revoke my consent for photo and video usage.

Name

give the staff of Autism Services of Florida permission to take digital photos and video recordings of my child,

Child's Name

to use for therapy, social media, and or educational purposes.

Name

DO NOT give the staff of Autism Services of Florida permission to take digital photos and video recordings of my child,

Child's Name

to use for therapy, social media, and or educational purposes.

Parent/Guardian Signature

Date

Section Break - Authorization for Release of Information

Client Name

First Last

Date of Birth

I hereby authorize the release of the following specific information (check all that apply):

History

Treatment

Evaluations

Diagnosis

Reports

Educational Records

Other (specify below)

Other Information

Pediatrician Name

Phone Number

Fax Number

SLP/OT/PT Name

Phone Number

Fax Number

Diagnosing Physician

Phone Number

Fax Number

Other Professional Name

Phone Number

Fax Number

I hereby give permission to release my child’s health/ medical/ psychological/ educational/ early intervention/ therapeutic records to and/or from Autism Services of Florida and to discuss my child’s care or treatment with appropriate professional staff. I understand that information in my child’s records will not be released to any other individual without my specific written consent. This authorization may be revoked at any time by my written statement. This authorization is given freely, voluntarily, and without coercion.

Signature of Parent or Guardian

Date

Section Break - Consent to Pick up or Drop off

Consent to Pick up or Drop off

I, the Parent or Guardian Name, give written consent that the people listed below have permission to pick up or drop off

Client Name, to Autism Services of Florida. In addition, I give these following people permission to be at a session when therapy is being conducted

Name

First Last

Relationship to client

Name

First Last

Relationship to client

Name

First Last

Relationship to client

Name

First Last

Relationship to client

Name

First Last

Relationship to client

Signature of Parent/Guardian

Date

Section Break - Medication Information

Name of Client

First Last

Date

List all medications both prescription and non-prescription, your child is allergic to:

Medication Name

Type of reaction, such as a rash or breathing difficulties

Use the plus sign to add additional rows

Medication List Use the chart below to list all the prescription and non-prescription medications/vitamins/ supplements your child currently takes. Be sure to fill in all the information for each medication.

Medication Name

Reason for taking the medication

Prescribing Doctor

Dose

How often?

Use the plus sign to add additional rows

Emergency Care (Explained)

Section Break - Attendance and Illness Policy

Attendance and Illness Policy

Failure to keep your scheduled appointments at Autism Services of Florida hinders our ability to provide the best care to our clients.

Please call at least 24 hours prior to your appointment if you are unable to attend. In the event of sudden illness or continued illness, please notify Nicole Edge and/or Anchell Downs one hour before your child’s appointment start time. Failure to notify Nicole Edge by this time will result in a $50 cancellation fee.

Please call, text, or email ([email protected] or [email protected]) Autism Services of Florida at (239) 349-3139 with all notifications. A voice message will also suffice. Our text messaging system is open 24 hours, so please text as soon as you are aware your child will be out.

If the client has run a fever, vomited, had diarrhea, green mucus from nose or throat, or a contagious illness 24 hours prior to your scheduled session, please notify Autism Services of Florida to cancel the session. If the client arrives for services and is presenting with above-mentioned symptoms, Autism Services of Florida has the right to cancel the session for the day. The client will not be able to return to the center until they are asymptomatic for 24 hours or has a doctor’s note stating a date in which they may return for services.

Repeated cancellations, “no-shows”, late arrival, late pickup, and early pickup are disruptive to the optimal delivery of care to you and our other clients. As a result, at the discretion of Autism Services of Florida, 3 late cancellations or no-shows within a month period may result in the discontinuation of services. Late cancellations or arrivals due to illness will be reviewed and may be excluded. Autism Services of Florida will send out a monthly letter to parents who are not meeting the attendance policy with outlined expectations that need to be met in order to continue services. Due to daily insurance billing requirements, certain insurance may need to be billed an additional fee for every 15 minutes if parents/guardians are late for pick up.

If you are reading this, behavioral therapy is deemed medically necessary for your child. This means that extended vacations are not permitted. Absences not only set your child back but are recorded by insurance companies. No more than 21 missed vacation days per calendar year will be acceptable. Autism Services of Florida must be notified one month in advance to a scheduled vacation. Discontinuation of services may result from truancy. Religious exclusions apply.

I, Name Below, understand Autism Services of Florida Attendance Policy and understand my responsibility to plan appointments/vacations accordingly and will notify Autism Services of Florida if I have difficulty fulfilling my scheduled appointments.

Signature of Parent/Guardian

Date

Section Break - Parent Training Policy

Parent training is a vital component of the continuity of services for your child. As a part of services, parents/guardian’s will be required to attend two parent training meetings per month. Each meeting will be held at the center with the parent and/or guardian, the assigned Board-Certified Behavior Analyst (BCBA), Registered Behavioral Technician (RBT), and client.

Please call at least 24 hours prior to your appointment if you are unable to attend. In the event of sudden illness, please notify Nicole Edge one hour before your appointment starts time. Failure to notify Nicole Edge by this time will result in a $50 cancellation fee.

Please call Autism Services of Florida at (239) 349-3139 with notifications. A voice message will also suffice. No text messaging of this information will be accepted.

Repeated cancellations, “no-shows” and late arrivals are disruptive to the optimal delivery of care to you and your child. As a result, at the discretion of Autism Services of Florida, 1 late cancellation or no-show within a month period may result in the discontinuation of services. Late cancellations or arrivals due to illness will be reviewed and may be excluded. Autism Services of Florida will send out a monthly letter to parents who are not meeting the parent training policy with outlined expectations that need to be met in order to continue services.

If you are reading this, behavioral therapy is deemed medically necessary for your child. This means that parent training is a vital component of therapy. Absences not only set your child back but are recorded by insurance companies. No more than 12 missed parent training meetings per calendar year will be acceptable. Discontinuation of services may result from truancy. Religious exclusions apply.

I, Name Below understand Autism Services of Florida Parent Training Policy and understand my responsibility to attend parent training for the continuity of services of my child and will fulfill my obligations as the parent/guardian.

Date

Signature of Parent/Guardian

Date

Section Break - Scholarship Information

Have you ever applied for any scholarships?

No

Yes

Name of scholarship

Amount awarded

Can the money be used for a variety of services or for only specific services? Please explain

Section Break - Acknowledgement of Receipt of Parent Welcome Packet

I/We, NAME BELOW

the parent(s) or legal guardian(s) of BELOW have received and read a copy of the “Intake Packet” from Autism Services of Florida, LLC

I understand and agree to abide by all guidelines as written, including, but not limited to those related to the cancellation policy. I understand that these guidelines may be modified at any time based on the needs of Autism Services of Florida and do not in any way constitute a guarantee of treatment. I understand that the Therapy Guidelines cannot be modified or amended except in a written document signed by the owner, Nicole Edge, of Autism Services of Florida. I understand that Autism Services of Florida may terminate therapy services at any time as permitted by applicable law. Likewise, I understand that I may withdraw my child from treatment at any time. I was awarded the opportunity to ask questions or discuss any concerns regarding this material and was provided the name of someone to contact should questions or concerns arise going forward.

Name of Client

First Last

Signature of Parent/Guardian

Date

CAPTCHA

Section - Notice of Health Information Privacy Practices

Notice of Health Information Privacy Practices

Acknowledgement of Receipt of the Rights of the Client

Section Break - Authorization for Release of Information

Section Break - Consent to Pick up or Drop off

Consent to Pick up or Drop off

Section Break - Medication Information

Section Break - Attendance and Illness Policy

Section Break - Parent Training Policy

Section Break - Scholarship Information

Section Break - Acknowledgement of Receipt of Parent Welcome Packet

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