Policies & Procedures

9141 Cypress Green Drive Ste 2 Jacksonville, FL 32256

(904) 647-1849

www.bloom-behavioral-solutions.com

Policies & Procedures

Please initial next to each section to acknowledge that you have read and agree to our practice policies

Treatment Fee Structure:

______ Clinical Treatment with Certified ABA Clinicians:

Rebekah Wotton, M. Ed., BCBA or Genevieve Covington, M.S., BCBA (Practice Owners): $175 per hour. BCBAs (Board Certified Behavior Analyst): $125 per hour

BCaBA (Board Certified Assistant Behavior Analyst): $100 per hour

This includes initial Parent Management Training assessments and all other direct and indirect services.

________ Clinical Treatment with Behavioral Instructors: $50 per hour. All of our Behavioral Instructors are working toward their Board

Certification in ABA. Additionally, our Behavioral Instructors are trained extensively in the principles of ABA, and developmental disorders. ________ Supervision of Behavioral Instructors Provided by Certified Clinicians: A minimum of 1 hour of supervision is required per 8 hours of

direct care provided by a behavioral instructor. However, per the BACB guidelines, supervision is provided as much as a clinical program may require. Thus, there may be variability in the supervision requirements of a treatment program.

________ On-Site Treatment with Behavioral Instructors (In-Home/ In-School): $60 per hour ________ Swim Lessons: $70 per hour

________ Travel: A fee of $1 per mile will be charged for travel to in-home settings for the purposes of in-home therapy outside of a 20 mile radius of our clinical location. Community therapy may include taking a patient off site to integrate them into the community setting.

Such environments may include but are not limited to, stores, job sites, playgrounds, etc. For any travel services provided by Bloom in which a practitioner is transporting the patient, the client is solely responsible for mileage charges. Such charges are also applicable for transporting a patient to or from the clinic when a client is unable to transport their child themselves. Group transportation such as field trips for summer camp are not included in the client’s financial responsibility.

________ Financial Responsibility of Personal Patient Supplies: The client is financially responsible for specific supplies required for the child’s treatment. Such exceptional items may include but are not limited to, special dietary needs, medication, extra clothing, toileting supplies,

augmentative communication materials, food and drinks (exception of water), special reinforcers, and any other specialized resources that fall outside of basic programming materials.

________ Supervision Requirements for Private Pay Clients: I. BCBAs do not require supervision.

II. Our BCaBAs are provided with supervision by a BCBA; however, our private pay clients are not financially responsible for this supervision.

2

__________ Miscellaneous Services: Additional services are offered that may include, but are not limited to, phone consultation, co-treatments, attendance of school meetings and IEPs, attendance of psychological evaluations, etc.

__________ Occupational Therapy: Treatment provided by a Florida licensed Occupational Therapist or Certified Occupational Therapy Assistant is $90 per hour

__________ Speech Therapy: Treatment provided by a Florida Licensed Speech Language Pathologist is $80 per hour __________ Super Sprouts Social Group: $90 per week (2 hours per week)

__________ Feeding Therapy: Please contact us for more information if you are interested in a feeding program.

Treatment Services

_________ Most of our direct care for ABA is provided by a behavioral instructor with clinical supervision provided by a certified practitioner.

_________ Treatment provided by clinical staff typically includes supervision of behavioral instructors, Consultation, Parent Management Training,

and Behavioral Intervention Plans that require the reduction of aggressive and/or self injurious behaviors. Direct care from a certified clinician may require medical necessity and/or clinician recommendation. However, such appointments are based upon clinician availability.

Appointments & Scheduling

_________Description of Services: We are able to provide treatment within the boundaries of your scheduling contract. Bloom is not

equipped to provide on-call services, or emergency treatment. In case of emergencies please contact 911, or your local non- emergency police line. In special circumstances and advanced scheduling we may accommodate meetings, PMT, off-site treatment, etc. outside of the patient’s consistent treatment schedule. Additionally, we want to provide excellent service to each of our clients. Part of our effort in ensuring client satisfaction is extensive communication between therapists and clients. We will often create a communication binder for patients to allow for effective communication between both parties. Please refrain from utilizing text messages and phone calls to our therapist’s personal cell phones outside of regular business hours (9:00 a.m. – 6:00 p.m. Mon.-Fri.). Outside of regular business hours you may email or call the clinic and leave a message for one of our staff.

_________ Scheduling Procedures: There are many variables incorporated with the development of a treatment schedule. Such variables include insurance coverage, treatment authorizations, permitted providers, and therapist availability. We will do our best to

accommodate requested days/times. However, please note that the aforementioned variables may impede certain requests. _________ Scheduling Contract: Once a set schedule is developed for a patient, the client will be provided with a scheduling contract that states

that they understand and will adhere to the treatment schedule.

_________ Arrival Procedures: If you arrive early to your appointment, you are more than welcome to wait in the lobby. Please note that our therapists typically have appointments back to back. Thus, in most cases we are not able to start the scheduled therapy session in advance if you arrive early. Please note, repeated late arrivals may lead to changes within the treatment schedule.

_________ Late Fees: Please arrive 10 minutes prior to the end of your therapy appointment to discuss the progress of the session. If you arrive more than 5 minutes past the scheduled ending time of your appointment, your account will be subject to a late fee of a $1 per minute late. In the event that late arrivals are reoccurring, your set schedule may be modified or no longer honored.

__________ Illness Policy: If a patient is ill please notify the clinic as soon as possible to reschedule your appointment. Illness for Bloom

Behavioral Solutions is defined as vomiting and/or diarrhea, having a fever, eyes or respiratory discharge, open sores that are not able to be covered, and/or having a known bacterial infections. In order to return to therapy, the patient must be free of a fever for 24 hours. In an effort to protect our patients and other staff, all employees must adhere to the same illness guidelines as our clients.

3

_________ Cancellations: Cancellations must be made 24 hours in advance. Failure to notify us 24 hours in advance will result in a $50 fee charged to the client account. Each client is allotted 3 cancellations within the 24 hour time frame per quarter (3 months). Cancellations in excess of 3 per quarter will be charged $50 per appointment regardless of prior notification, including cancellations made 24 hours prior to scheduled appointments. Clients with excessive cancellations may forfeit their scheduled time slot(s). Additionally, excessive late arrivals to therapy may be considered a cancellation and therefore subject to a cancellation fee. Under special circumstances, additional cancellations with prior notification or a leave of absence from treatment may not incur such charges with preapproval from chief operating staff. ***Please Note: Our cancellation policy is to protect the integrity of therapeutic services and our therapist's time and availability. When an appointment is made with a specific provider, that time slot is no longer available for booking. Additionally, excessive cancellations may affect the prognosis of the patient's treatment plan.

Payments

________ Payments are due at the time services are rendered. Payments include private pay fees, co-payments, cost shares, unmet

deductibles, and any other miscellaneous charges. Bloom requires that private pay patients and those whose insurance coverage includes a deductible, copay, or coinsurance must provide credit or debit card information on the attached credit card sheet. Services

not paid for at the time treatment was rendered will be billed to the client or charged to the credit card on file. __________ If payments are not received during times that services are rendered and a credit card is not on file, an invoice will be provided to the

client. In such cases, invoice payments are due upon receipt.

__________ Payments not received 30 days past date of service are considered late. Past due accounts are charged a late fee of 10% of the total bill and are subject to being sent to collections.

__________ In some cases, materials may be purchased for the client. Such purchases may include food, diapers, etc. These items will go on an invoice and must be paid at the time services are rendered.

Credit Card Authorization

Payment for services is due at the time services are rendered. This includes payment in full for private pay clients and client portion of all services not covered by insurance for clients covered by health insurance. These fees may include, but are not limited to, deductibles, copayments,

coinsurance, and any procedures and services that are not reimbursed by insurance. In addition, charges such as travel fees, cancellation fees, late pick up fees, and supply costs are due at time of service. Clients may pay using a check or credit card at the time of service, or Bloom will charge the credit card listed below.

Card Type (circle one): VISA MASTERCARD DISCOVER AMERICAN EXPRESS

Name on Card: ________________________________________________________________________________ Card Number: _________________________________________________________________________________ Expiration Date: ________________________________ Security Code (CVV): _____________________

Billing Address: ________________________________________________________________________________ Billing Zip Code: _________________________________

By signing below, I give Bloom Behavioral Solutions, Inc. permission to charge the above listed credit card for any charges incurred for patient ________________________________ (patient’s name).

4

Verification of Insurance Benefits

________

Please initial to confirm that you agree to allow Bloom Behavioral Solutions to contact your insurance provider to determine coverage of benefits. Personal information such as SSN and Policy/Group numbers are required to provide this service. Additionally, your initials signify your agreement that you are financially responsible for all billable treatment in the event that your insurance company does not cover ABA services.

Primary Care Physician: ___________________________ Insurance Provider:_______________________________________ Insurance Phone Number (Number on back of Insurance card): ___________________________________________________ Group Number:________________________________ Policy Number:______________________________________________ Patient SSN:__________________________________ Policy Holder’s SSN:__________________________________________

Client Confidentiality

_________ Limitations of Confidentiality

Bloom Behavioral Solutions takes every precaution to protect the rights and personal information of their clients. Any written or verbal information obtained in this intake profile or other treatment services will not be disclosed to any individual(s) without written consent from the client. The client is defined as the patient if over 18 years of age, unless deemed mentally incompetent to understand their legal rights regarding limitations of

confidentiality. Otherwise, the client is the parent or legal guardian of the patient. Please note the following are legal limitations to confidentiality, meaning we are held liable by the state of Florida to provide confidential information in the following cases:

 If the patient is determined to be in imminent danger of harming them self or others  If the client discloses abuse or neglect of children

 Suspected abuse or neglect

 To qualified personnel for certain kinds of audits or evaluations  In a criminal court proceeding

 In legal or regulatory actions against a professional

 In proceedings in which a claim is made about one's physical, emotional, or mental condition

 When disclosure is relevant to any suit affecting the parent-child relationship, which includes divorce and child custody deliberations.  Where otherwise legally required

Every staff member of Bloom Behavioral Solutions and Bloom Rehabilitative Services is a mandated reporter by law. We are legally bound to report any known or suspected instance of abuse or neglect. Please do not hesitate to contact us if you have any questions or concerns regarding these limitations of confidentiality.

Expectations from Caregivers and Guardians for Clinical and On-Site Treatment

_________ To ensure the continuity of care it is essential that caregivers participate in the treatment plan of the patient. Caregivers such as

parents or legal guardians are expected to attend quarterly meetings with therapists and supervisors to review current prognosis and

5

further clinical expectations. Your therapist/supervising clinician may require you to collect data in the home environment to track behavioral progress. This is an integral part of therapy, and necessary for appropriate modifications to treatment plans. Additionally, caregiver training may be a program requirement based upon treatment goals and generalization of skill acquisition.

__________ Contingency Contracts may be required based upon your child’s program and amount of necessary caregiver training.

__________ Caregivers are responsible for all materials necessary to provide for a patient’s basic needs and treatment program. This may include, but is not limited to food, additional clothing, reinforcers, communication devices, toileting materials, etc. In the event that necessary materials are not sufficiently provided, Bloom may provide such resources and bill the client for the amount purchased.

__________ In-Home Requirements Responsibilities of the Client:

A parent or caretaker must be present during the therapy session if there are children other than the patient such as siblings that are also present. A parent or caretaker is not required to be present during the therapy session if there are no children other than the patient left in the home. In the event that the parent or caretaker leaves the home during the therapy session, they must return at least 10 minutes prior to the end of therapy. A therapist may only leave a patient with caretakers that are listed under the caretaker section.

It is the responsibility of the parent or caretaker to provide a therapeutic environment in the home that is free from distractions or

interruptions. In most cases, this includes pets or siblings that could interfere with the progress of the session. In some circumstances, the therapist may request the presence of parents or siblings for training purposes. In some situations, problem behaviors may occur. These behaviors might include, but are not limited to verbal or physical aggression, property destruction, self injurious behaviors, etc. Our in-home therapists are trained extensively on how to deescalate problem behaviors. Therefore, it is imperative due to company policy, involvement from parents or caretakers is not permissible unless otherwise stated or a caretaker training session is in place. Based on the environment, a therapist might choose to work with the patient in a room with closed doors, such as the child’s bedroom. This is a common practice in therapy depending on target skills and environmental factors.

I. The client must provide necessary materials for the patient that will facilitate therapeutic progress. Such materials often include edibles or other reinforcing items that are typically used in verbal behavior programs. The therapist may request specific items that will be necessary for specific behavioral targets.

II. The client understands that Bloom Behavioral Solutions, Inc. is not responsible for other children in the household that are not patients of the company. Additionally, the company is not responsible for pets.

III. Bloom Behavioral Solutions, Inc. is not responsible for loss or damages of property. Such damages include fire and flood.

__________ Travel

Due to circumstances out of our control (i.e. traffic, weather) our on-site appointment times may vary within 15 minutes. Thus, please allow up to 15 minutes after your scheduled appointment for the arrival of our therapists. In the event that your therapist will be later than 15 minutes, you will receive a call from our office manager.

Transportation Procedures

_________ I (Legal Guardian) give permission for my child to be transported in a motor vehicle driven by any staff member of Bloom Behavioral Solutions, Inc. I recognize that by participating in this activity, as with any activity involving motor vehicle transportation, my child may risk personal injury or permanent loss. I hereby attest and verify that I have been advised of the potential risks, that I have full knowledge of the risks involved in this activity and that I assume personal expenses that may be incurred to treat my child in the event of an accident, illness, or other incapacity.

As a condition for the transportation received, I, for myself, my child, my executors and assigns, further agree to release and forever discharge Bloom Behavioral Solutions, Inc. and their agents, officers, employees and volunteers from any claim that I might have myself or that I could bring on my child’s behalf with regard to personal injury, personal loss, damages, demands or actions whatsoever, including those based on negligence, in any manner arising out of this transportation. I have read this entire waiver and permission form, fully understand it, and agree to be legally bound by its terms.

6

_________ I agree to provide any transportation materials (i.e. car/booster seats) necessary to transfer my child in a motor vehicle. I also agree that failure to provide such materials may result in a cancellation of the treatment appointment.

Emergency Contact Information and Procedures

_________ I give any staff or clinician of Bloom permission to contact any pertinent member of a medical or emergency staff in the event that my

child requires such care. Additionally, I give my written consent to contact and release confidential information for the purpose of a medical emergency.

Name Relation to Patient Phone Number

Name Relation to Patient Phone Number

Name Relation to Patient Phone Number

Name Relation to Patient Phone Number

Name Relation to Patient Phone Number

Name Relation to Patient Phone Number

Name Relation to Patient Phone Number

Name Relation to Patient Phone Number

Audiovisual Policy

Bloom Behavioral Solutions utilizes pictures and video recording for multiple purposes. Clinical rationale for the use of pictures and video recording of patients include treatment review, tracking behaviors, progression analysis, and training of staff and caregivers. For the protection of our patients, the entire premises of the clinic location is under 24 hour video surveillance.

Occasionally Bloom utilizes pictures for marketing purposes. If you DO NOT consent to your child’s photo being used for marketing purposes, please check the box below.

I do NOT consent to my child’s picture being used for marketing purposes (e.g. practice website, brochures, monthly newsletter, and other related publications)

Patient Pick-Up and Release of Information

The following individuals have permission to pick up my child from Bloom Behavioral Solutions and obtain information regarding therapy sessions. Please list ALL persons you wish to grant permission to. Patients will not be released to any individual not on this form without prior consent.

Name Relation to Patient Phone Number

Name Relation to Patient Phone Number

Name Relation to Patient Phone Number

Name Relation to Patient Phone Number

Name Relation to Patient Phone Number

Name Relation to Patient Phone Number

Name Relation to Patient Phone Number

7

Authorization to Administer Medication

***Please note, it is company policy for the safety of our patients that medication can only be administered by our office manager Jessica Moseley or Clinical Director Justin D’Ambrosio. In the event of the absence of both of the listed individuals, medication will be administered by one of the company owners. All other staff including therapists are not permitted to administer medication to ANY client. Medication must be in original packaging with prescription label including patient’s name and dosage information affixed to the bottle, or a copy of the original prescription, or a letter from physician and/or pharmacist outlining dosage information.

Discharge and Transfer of Service Procedures

_________ It is common for therapists to refer a client to a different practice to accommodate the specific needs of a patient and/or adhere to company policies. Additionally, failure to adhere to contingency contracts between Bloom Behavioral Solutions, Inc. and the appropriate client parties, transfer and discharge procedures may take place. Please refer to your individual contracts with your therapists for specific discharge criteria.

Bloom Behavioral Solutions, Inc. adheres to all required ethical standards and guidelines from the BACB and the enforceable standards of the APA for all services, including discharge and transfer of service procedures. Bloom Behavioral Solutions, Inc. reserves the right to cease services if the client does not adhere to the company policies outlined in the present document. Bloom Behavioral Solutions, Inc. does not discriminate between race, gender, religious belief, or sexual orientation.

***By signing below you agree to the terms and policies for Bloom Behavioral Solutions, Inc. Thank you for your compliance

with our practice guidelines.

_______________________________________________ _______________________________________

Client Signature Date

Patient Name: Client/Guardian Name: Illness Medication

is Used for:

Name of Medication Dosage How to be Administered Times of Administration Dates-Medication Time Period

AM PM

From To

AM PM

AM PM

AM PM

Additional Information/Special Instructions/ Contraindications-Specify:

I hereby authorize clinical staff of Bloom Behavioral Solutions to administer the above medication(s) to my child according to the schedule and dosage amount as stated above.

8

9141 Cypress Green Drive Ste 2 Jacksonville, FL 32256

(904) 647-1849

www.bloom-behavioral-solutions.com

Records Release Consent Form

1. I, __________________________________________________________ (parent/legal guardian name), the parent/legal guardian of ______________________________________________________________ (Child’s name and date of birth), am completing this form to allow the use and sharing of my child’s protected health information.

2. I authorize the behavior analysts and therapists with Bloom Behavioral Solutions, Inc. who are serving my family and child to share information regarding my child’s treatment and service provision with the below noted individuals and/or organizations:

List below the individuals and/or organizations with which you authorize the sharing of information. Please be sure to provide contact information and complete address for each individual or organization.

Name Position Organization Address Phone Fax Name Position Organization Address Phone Fax Name Position Organization Address Phone Fax

3. The information will be used/disclosed for the following purposes (ex: continuity of care, custody hearing, etc.) ____________________________ ______________________________________________________________________________________________________________________ 4. I understand and agree that this authorization will be valid during the time my child is receiving treatment through Bloom Behavioral Solutions, Inc. or during the time span noted here: _________________________________________

5. I understand that I can revoke or cancel this authorization at any time by sending a letter to Rebekah Wotton or Genevieve Covington at Bloom Behavioral Solutions via email to ([email protected]) or via mail at 9141 Cypress Green Dr. Ste, 2, Jacksonville, FL 32256. If I do this, it will prevent any disclosures after the date it is received but cannot change the fact that information may have been sent or shared before that date.

6. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my child’s access to treatment through Bloom Behavioral Solutions, Inc.

7. I understand that I may inspect and have a copy of the health information described in this authorization.

____________________________________ ______________________________________ _______________ Parent or legal guardian printed name Parent or legal guardian signature Date