Patient Registration Form

3121 N Oak Street Ext

Tel: 800-832-9419 Fax: 1-855-859-1671

Email: info@compassaid.com

www.compassaid.com

Patient Registration Form

Thank you for selecting Compass Behavioral & Developmental Consultants, LLC to help you meet the needs of your child.

The attached packet of information will help inform you about Compass BDC policies and procedures and allow you time to gather information prior to your intake appointment. This information will be shared with the BCBA assigned to your case, should you proceed with ABA therapy, prior to your initial meeting with them. In each instance, the BCBA is responsible professionally for all services provided to you and your child.

Thank you for the trust that you are placing in us to assist you and your family. We understand that some of these forms may be challenging, time-consuming, and in places redundant. We want you to know that the more information that we have the better able we will be to assist you and your family. If at any time in this process you have any questions, please contact us.

We look forward to meeting you and your child, Compass Behavioral & Developmental Consultants, LLC.

Please return Intake Packet to us prior to the initial appointment.

Fax: 855-859-1671

Current Locations:

Valdosta, GA - Clinic 1

3121 N Oak St Ext

Valdosta, GA 31602 United States

Tel: 800-832-9419 ext 1

Email: officev@compassaid.com

Valdosta, GA - Clinic 2

2935 N Ashley St Suite 120

Valdosta, GA 31602 United States

Tel: 800-832-9419 ext 1

Email: officev@compassaid.com

Lakeland, GA - Clinic

34 East Main St

Lakeland, GA 31635 United States

Tel: 800-832-9419 ext 1

Email: officev@compassaid.com

Thomasville, GA 

602 Victoria Place Suite A

Thomasville, GA 31792 United States

Tel: 800-832-9419 ext 3

Email: officet@compassaid.com

Warner Robins, GA 

225 Smithville Church Rd, Suite 1100

Warner Robins, GA 31088 United States

Tel: 800-832-9419 ext 4

Email: officew@compassaid.com

Getting Started with ABA Therapy

1. Complete Intake Packet and send it back to us

• Insurance Information with Insurance Card, front and back (if applicable)
• Fee Schedule
• Referral for ABA from Child’s Primary Care Doctor or Specialty Provider
• Psychological Evaluation with Diagnoses
• Signed HIPPA Service Agreement and Consent Form (included in this packet)
• Patient Confidentiality Contact Form (included in this packet)
• Request/Authorization to Release Confidential Medical Records & Mental Health Records (included in this packet)
• Documents of prior ABA (Optional –if available/applicable)
• Current IEP/IFSP/504 (Optional –if available/applicable)

2. Appointment will be set for Initial Assessment with BCBA/BCaBA/QASP to develop treatment goals where your child will be assessed in person. At that time BCBA/BCaBA/QASP will advise you whether other assessment tools would be utilized such as VB-MaPP, ABLLS-R, PDDBI, PEAK.

3. After Assessment is complete please allow up to 2 weeks so that we can submit BSP to your insurance for pre-authorization of ongoing services.

4. After we receive pre-authorization, our office staff will contact you to arrange ongoing services.

5. Arrangement of schedule for In-Home/Clinic Therapists and Supervisors visits will follow within a week or two after initial BSP is completed and authorization obtained.

6. Services will include direct ABA Therapy, Plan Modification, Parent Training and Supervision of a Technician. Every 3-6 months a progress update will be submitted to your insurance. At this time parents/guardians will assist with PDDBI and other required evaluations and doctor referrals, if required.

7. Please contact our office if you have any questions and we will do our best to guide you.

INSURANCE REIMBURSEMENT FORM

FINANCIAL & BILLING POLICY AGREEMENT

New patients approved for ABA Therapy services are responsible for any and all charges not paid for by healthcare insurance payers (private of public). By signing this client agreement, you are acknowledging that you understand this condition of service and commit to promptly paying Compass BDC LLC for the services we provide to you, our valued customer.

Compass is responsible for providing quality therapy to the child and therefore, the child’s parent (or guardian) is responsible for all charges incurred. Due to the many changes in insurance policies, it is no longer a simple task to interpret each and every policy. Although we try to stay aware of any changes, it is not always possible. It is your responsibility, as the subscriber, to know and understand your individual coverage and to immediately notify us if any changes occur.

*All services are subject to pre-authorization and insurance claim processing.

Insurance: Compass is committed to helping maximize each child’s insurance benefits. Insurance policies vary greatly, therefore, owing to the complexity of insurance contracts; we can only estimate benefits in good faith. Compass will contact your insurance carrier for a “quote of benefits” and will obtain necessary pre-authorizations, but coverage cannot be guaranteed.

In the event the insurance company does not provide payment within the agreed amount of time or denies the payment, the balance becomes that of the financially responsible party. To avoid any payment delays from your insurance carrier, please let Compass know of any and all updated information regarding your plan and ABA Therapy coverage. Please let us know immediately if you receive a new insurance card or if your child is covered under new or additional insurance. The responsible party will be billed for services not covered or denied if Compass is not notified in a timely manner of any changes. In addition, Compass has the right to suspend services until new insurance is verified and/or necessary pre-authorizations are in place.

If the responsible party wishes to continue services before insurance is verified and/or pre-authorization is in place, the responsible party will be required to privately pay for those services at the end of each week. If you have questions regarding our financial policy, please do not hesitate to discuss them with us. For your convenience, we accept Master Card, Visa, Cash, HSA Cards, Checks, and have safe and convenient payment online at: compassaid.com/payment

Private Pay: Families who do not have insurance coverage for ABA may choose to pay privately for ABA Therapy. Services are billed in advance on a mon-to-month basis for pre-scheduled ABA Therapy sessions. Pre-paid fees are non-refundable in absences. Our fees are comparable usual and customary fees in the area.

Cancellation: Compass schedules a 1:1 ABA Technician to work specifically with your child for the duration of his/her scheduled sessions. Any cancelations require at least a 24-hour notice so our staff’s schedule may be adjusted accordingly. We understand that there may be days when your child is ill and will need to stay home. Therefore, Compass BDC LLC can grant one (1) sick day per month at zero penalty. Any additional absences within the same month (with less than 24-hour notice) will be charged at $50-100 per day. Excessive cancellations may result in dismissal of services or reassignment of therapists. Any instance of a week or more vacation may result in reassignment of therapists upon return. Please see the “Therapy Attendance Policy” and the “Cancellation & Late Policy Fees” for further information.

Payments: All copays are due at the date of service. Being that we work in an environment with children we will email statements for patient responsibility weekly. Weekly invoices are due within two (2) calendar days of invoicing for continued services. Payments can be made directly through the website: compassaid.com/payment

Credit Card on File for Pre-Payment: To ensure a smooth billing process, Compass requires a credit card to remain on file which will be automatically billed after six (6) days of invoicing, along with a $25 late fee. A $35 fee will be charged for declined payments, if another form of payment is not provided within 24-hours of notification of the declined payment. If a payment is declined, Compass may suspend services until payment is made. You may choose to pre-pay 30 days in advance without having a Credit/Debit card on file for reoccurring charges. 

NOTE – Credit card on file for pre-payment is only required if there is patient responsibility.

Collection Fees: Fees incurred to collect payments will be billed to and payable by the Responsible Party. This includes attorney fees and court costs.

Note to Separated or Divorced Parents: Compass will not keep separate accounts to accommodate separated or divorced parents who share financial responsibility.

I understand and agree that I am responsible for the payment of all charges incurred, in the time frames described above, regardless of any insurance coverage or other plans available to me. Additionally, I understand and agree to pay any and all collections, costs, and/or attorney’s fees if any delinquent balance is placed with an agency or attorney for collection, suit, or legal action. I also acknowledge that confidentiality is waived in matters involving collections and the sharing of information sufficient to pursue recovery of debts owed.

Contact Information

Parent/Guardian Contact Information:

Responsible Party Contact Information (if different from Parent/Guardian):

MEDICAL HISTORY

Please List Child's Current Medications:

EDUCATIONAL HISTORY

Parent/Guardian Contact Information:

Does your child receive SLP/OT/PT services at school and outside of the school?

Communication Skills:

Social and Play:

PARENT/FAMILY PRIORITIES & PREFERENCES

Top three areas/goals you would like to see change for your child in the next 6 months:

BEST TIME FOR THERAPIES

*Usually sessions at the clinic or in the home are 2-3 hours; at school/daycare sessions might be longer but are still at least 2 hours. Our hours for sessions are usually 9am to 7pm weekdays. Based on need we may be able to accommodate earlier, later, or weekend sessions.

** We are providing services in various locations based on child’s needs, such as clinic, family home, school, and daycare and afterschool programs.

CONSENT AND RELEASE

I hereby consent to treatment by, and authorize insurance benefits to be paid directly to, Compass Behavioral & Developmental Consultants LLC. I agree that I am responsible to pay 1) for services not covered by my insurance company, 2) co-payments and deductibles, and 3) any expense associated with the collection of a debt owed to them by me (i.e. Attorney fee, court cost or collection agency fee). I also consent to the release of pertinent medical information to my insurance carrier(s) for the purpose of processing health care claims.

HIPAA AND SERVICE AGREEMENT

Your signature(s) below indicates that you have received HIPPA and Privacy Information Notices and that I have read the information in this document and agree to be bound by its terms, and that you have received the HIPAA notice form described above or have been offered a copy and declined. Consent by all parents/legal guardians (those with legal custody) is required.

INFORMATION SHARING AND HIPPA

I give consent to my Therapist, as a contractor for Compass Behavioral & Developmental Consultants LLC to discuss my child’s progress and behaviors with their supervising BCBA/BCaBA, their coworkers, and/or any relevant school personnel, speech therapists, occupational therapists. Etc. in the spirit of obtaining new ideas and skills or in an effort to share information that will be beneficial to either party in providing the best possible services for the child.

I give permission and consent for Compass BDC and the staff to use web cam while in session with my child and/or myself during the time my child is enrolled in services, only for accessional remote supervision by a BCBA/BCaBA. I understand that sessions will not be recorded and disbursed, and my child’s privacy will be protected.

CONFIDENTIAL RELEASE FORM

The information that may be released includes: 

• Physical Examination
• Birth Record
• Medical Examination
• Psychological Examination
• Psychosocial History
• IEP/IFSP
• Progress Notes
• Summary of Treatment to Date
• Discharge Summary
• After Care Plan
• Medication Record
• Education Record

I understand that I need not consent to the release of this information. However, I choose to do so willingly and voluntarily for the purpose(s) specified above.

I understand that I may revoke this authorization at any time (except to the extent that action has been taken in reliance thereon), by written, dated, communication to the Office of Compass Behavioral & Developmental Consultants LLC.

THERAPY ATTENDANCE POLICY

As a preventative reminder, please consider that if you qualify for ABA Therapy with Compass Behavioral & Developmental Consultants LLC, it is important to be consistent in attending therapy sessions.

Why is consistent attendance important?

Client’s need regular contact with the therapist familiar with their individual needs. This usually increases the rate of progress on individualized goals. In the long run, this is the most cost-effective thing to do because the goals will be reached sooner (assuming the child is practicing between sessions).

As professionals trained in providing specialized therapies, we ethically are to recommend what we believe is needed for the client based on assessment and observation. It is important for families to try as much as possible to follow our recommendations about how much therapy is needed.

Insurance companies expect their participants to attend recommended treatment on a consistent basis because following the course of treatment recommended for the client is part of efficient use of benefits. We must document attendance as a part of our records and progress reports.

The therapist has set aside time in his/her schedule to be available for you or your child. He/she usually cannot schedule anyone else for your time. Therapists prepare for your visits prior to appointments. Frequent or late cancellations result in the therapist spending unnecessary time in preparation.

Attendance Policy

Cancellation must only occur in the case of a true illness (fever or sick enough to miss school or go to the doctor) or family emergency. As with other professional services, you will be charged $50-$100 depending on hours of scheduled treatment that are missed (outlined below).

One sick day will be allotted per month and make up sessions will be offered the same week of the missed session.

Therapy must be cancelled 24 hours in advanced or the client will be charged for the missed appointment. Please remember that this fee is not billable to the insurance company, so it will be the responsibility of the family.

Vacations require at least 2 weeks advanced notice, with more notice given whenever possible.

Late Drop-off Policy

Please notify Compass as soon as possible if you are going to be dropping your child off late. We reserve your ABA therapist to work with your child one on one. Sessions that begin late due to delays on the part of the family cannot be extended or rescheduled as we cannot guarantee ABA therapist availability at other times. In situations where a family has dropped their child off late 3 or more times in a month, we will call a meeting to consider rescheduling appointment times. In extreme circumstances we may be required to terminate services due to your insurance provider’s policies.

Late Pick-up Policy

Please notify Compass as soon as possible if you know you are going to be late to pick up your child. If you anticipate that you will be more than 15 minutes late, it is recommended that you make alternate arrangements for a timely pick up.

At 5 minutes late to pick-up, the provider will call parent/guardian to assess the situation. If no contact is made by 15 minutes after scheduled pick-up, the provider will attempt to contact those listed on the emergency contact list. If we are unable to confirm an authorized pick-up within 1 hour after pick-up time, the appropriate authorities will be contacted so they can further investigate the circumstances.

Consistent cancelations will result in reassignment of therapies.

CANCELLATION & LATE POLICY FEES

In order to best provide services, Compass BDC, LLC adheres to the following fee schedules for our cancellation and late policy:

Situation Fee

No Call - No Show: Any session that does not start within 10 minutes of scheduled time and family has not contacted Compass BDC, LLC prior to scheduled time.    

$100 

Cancellation: Any session that is cancelled with less than 24 hours’ notice.    

$50 

Late Drop-Off: Family has informed Compass BDC, LLC that child will be present but more than 10 minutes after session start time. After 10 minutes, cancellation charge applies.  

10+ mins: $50 

Late Pick-Up: Family picks up child 10 or more minutes after scheduled session end time.  

10+ mins: $50

I have read this information regarding the importance of therapy attendance and understand that I will be charged for late cancellations as stipulated in the financial policy.

HIPPA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures of PHI

Your PHI may be used and disclosed by your physician our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coYou have the right to request a restriction of your PHI: This means you may ask us not to use or disclose any part of your PHI for the purpose of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to a family member or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices, your request must state the specific restriction requested and to whom you want the restriction to apply. ordination or management of your health care with a third party. For example, we would disclose your PHI as necessary, to a home health agency that provides care with you. For example, your PHI may be provided to a physician to whom you have been referred, to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your PHI will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for therapy services that may require that your relevant PHI be disclosed to obtain approval for the approved therapy services.

Healthcare Operation: We may use or disclose, as needed, your PHI in order to support the business activities of your physician’s practice. These activities include, but not limited to, quality assessment activities, employee review activities, training or medical students, licensing and conducting or arranging for the other business activities. For example, we may disclose your PHI to medical school students that see patients at our office. In addition, we may use sing-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment.

We may use or disclose your PHI in the following situations without your authorization. These situations include: As required by law, Public Health Issues as required by law, Communicable Disease, Health oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal proceedings, Law Enforcement , Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity and National Security, Workers Compensation, Inmates, Required uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of section 164,500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, Authorization or Opportunity to object unless required by law.

You may revoke the authorization at any time in writing, except to the extent that your physician or the Physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization

You have the right to request a restriction of your PHI: This means you may ask us not to use or disclose any part of your PHI for the purpose of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to a family member or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices, your request must state the specific restriction requested and to whom you want the restriction to apply.