Drop us your phone number and email, and we will contact you right away.
Please complete this packet for your child and return it to us. Typing your name in a signature field serves as your legal signature.
Por favor complete este paquete para su hijo/a y devuélvalo. Escribir su nombre en un campo de firma sirve como su firma legal.
This authorizes the release of specific information to Autism Behavioral Consultants. If the member is a minor, a parent or legal guardian must sign. This authorization expires one year from the date of signature and may be revoked in writing at any time.
Esta autorización permite divulgar información específica a Autism Behavioral Consultants. Si el asegurado es menor de edad, debe firmar un padre o tutor legal. Vence un año después de la fecha de firma y puede revocarse por escrito en cualquier momento.
Information to be released to / Información para: Autism Behavioral Consultants, 140 Worcester-Providence Turnpike, Unit 4, Sutton, MA. Expires one year from signature; revocable in writing.
I consent to necessary examination and/or treatment for my child by Autism Behavioral Consultants staff. I authorize release of information necessary to process claims and request payment of benefits to ABC for services provided.
Doy mi consentimiento para exámenes y/o tratamiento de mi hijo/a por parte del personal de ABC. Autorizo la divulgación de información necesaria para procesar reclamos y pido el pago de beneficios a ABC por los servicios prestados.
H0031 U2 – Assessment & case planning by a BCBA · H0032 U2 – Supervision by a BCBA
H2012 U2 – Parent training by a BCBA · H2019 U2 – Direct instruction by a paraprofessional
Telehealth lets you meet with your provider by phone, computer, or tablet from any location. It is optional — only consent if you wish to use it. You may stop at any time by calling (508) 219-6009. Technical issues may occasionally interrupt a visit, and your provider may still recommend an in-person visit.
La telesalud le permite reunirse con su proveedor por teléfono, computadora o tableta desde cualquier lugar. Es opcional. Puede dejar de usarla en cualquier momento llamando al (508) 219-6009.
Autism Behavioral Consultants collects protected health information and follows HIPAA privacy rules. We do not use or disclose this information unless permitted or required by law, and we limit disclosures to the minimum necessary. Protected information may include name, phone, address, date of birth, Social Security number, service dates, and diagnosis.
ABC recopila información médica protegida y cumple con las reglas de privacidad de HIPAA. No usamos ni divulgamos esta información a menos que la ley lo permita o exija, y limitamos las divulgaciones al mínimo necesario.
For questions or another copy, contact / Para preguntas o copia: Autism Behavioral Consultants, c/o Legal Department.
I acknowledge that I have received, reviewed, and understand ABC's Notice of Privacy Practices, including who to contact with questions or complaints.
Reconozco que he recibido, revisado y entiendo el Aviso de prácticas de privacidad de ABC.
Entered between the Parent (signatory) and Autism Behavioral Consultants LLC, a corporation organized under the laws of the Commonwealth of Massachusetts.
1. Consultant is responsible for: developing an ABA program based on assessment of the child's current abilities; recommending materials; assisting in recruiting and training therapists; and monitoring the program, including team meetings, data analysis, and recommending changes as the child progresses.
2. Parents are responsible for: establishing a day-to-day therapy schedule, ensuring hours are utilized and missed hours made up, day-to-day management of therapists, and accommodations for the program (e.g., a therapy room).
3. Parent and Consultant will set a mutually convenient schedule. Parents are recommended to utilize at least 80% of scheduled hours so the Consultant can provide services effectively.
THE SUCCESS OF ABA IS HIGHLY DEPENDENT UPON THE NATURAL ABILITIES OF THE CHILD, THE DEDICATION AND CONSISTENCY OF TREATMENT, AND THE NUMBER OF HOURS UTILIZED BY THE PARENT.
El éxito de ABA depende en gran medida de las habilidades naturales del niño, la dedicación y consistencia del tratamiento, y la cantidad de horas utilizadas por los padres.