Inhome Aba Program Intake Packet (Page 17 of 27) in pdf

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Teaching Skills for Success

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PATIENT R IGHTS

HIPAA p rovides y ou w ith s everal n ew o r e xpanded r ights w ith r egard t o y our C linical R ecord a nd

disclosures o f p rotected h ealth i nformation. T hese r ights i nclude r equesting t hat w e a mend y our r ecord;

requesting r estrictions o n w hat i nformation f rom y our C linical R ecord i s d isclosed t o o thers; r equesting a n

accounting o f m ost d isclosures o f p rotected h ealth i nformation t hat y ou h ave n either c onsented t o n or

authorized; d etermining t he l ocation t o w hich p rotected i nformation d isclosures a re s ent; h aving a ny

complaints y ou m ake a bout o ur p olicies a nd p rocedures r ecorded i n y our r ecords; a nd t he r ight t o a p aper

copy o f t his A greement, t he a ttached N otice f orm, a nd o ur p rivacy p olicies a nd p rocedures. W e a re h appy

to d iscuss a ny o f t hese r ights w ith y ou.

CONTACTING U S

Given t heir m any p rofessional c ommitments, o ur p rofessionals a re o ften n ot i mmediately a vailable b y

telephone. I f y ou n eed t o l eave a m essage, w e w ill m ake e very e ffort t o r eturn y our c all p romptly ( within

24-‐48 h ours w ith t he e xception o f h olidays a nd w eekends.). I f y ou a re d ifficult t o r each, p lease l eave s ome

times w hen y ou w ill b e a vailable. B ecause o f t he n ature o f t he s ervices w e p rovide, w e d o n ot p rovide o n-‐

call c overage 2 4 h ours p er d ay, 7 d ays a w eek. I n e mergency o r c risis s ituations, p lease c ontact y our

physician, o r c all 9 11 a nd/or g o t o t he n earest h ospital e mergency r oom.

CONSENT:

Your s ignature(s) b elow i ndicates t hat y ou h ave r ead t he i nformation i n t his d ocument a nd a gree t o b e

bound b y i ts t erms, a nd t hat y ou h ave r eceived t he H IPAA n otice f orm d escribed a bove o r h ave b een

offered a c opy a nd d eclined. C onsent b y a ll p arents/legal g uardians ( those w ith l egal c ustody) i s r equired.

___________________________

Client o r C hild’s n ame

_____________________________ _ ____________________________

Client o r C hild’s s ignature D ate

_____________________________ _ ____________________________

Parent/Guardian # 1 n ame P arent/Guardian # 2 n ame

_____________________________ _ ____________________________

Parent/Guardian # 1 s ignature P arent/Guardian # 2 s ignature

Inhome Aba Program Intake Packet Page 17