ALL TOGETHER LBA PLLC CONSENT FORMS

I hereby further direct that a copy of this authorization shall be deemed to be as valid as the original for all purposes authorized herein

ALL TOGETHER LBA PLLC

NOTICE OF PRIVACY PRACTICES

Please review the information carefully as this notice describes how medication information about you may be used and disclosed and how you can get access to this information

As a Behavioral Services Provider, All Together LBA PLLC so required by federal law to take reasonable efforts to maintain the privacy of your medical information. In the course of evaluation and treatment All Together LBA PLLC may receive and maintain medical information from other medical providers from whom you have received services. This is known as Protected Health Information (PHI). In accordance with the law, All Together LBA PLLC will at all times take reasonable actions/steps to secure client records, espouse clear privacy procedures and restrict other parties’ access to your PHI. You can obtain copies of your records and authorize transfer of your records to other providers as may be necessary. All Together LBA PLLC will not disclose your PHI without your permission, except as described in this notice. If you have any questions regarding this notice and policies for safeguarding your PHI please do not hesitate to ask.

All Together LBA PLLC has the right to revise privacy practices and implement new policies on a going forward basis to all PHI. If a new change is implemented this notice will be amended and posted in the office. Clarification of changes may be made available upon current request as well. This notice is effective and current as of September 1, 2020.

Uses and Disclosures:

Protecting client confidentiality and maintaining your PHI is something All Together LBA PLLC takes very seriously. All Together LBA PLLC strives to protect and secure all electronic and physical records as well as electronic and telephonic communications with you. Pursuant to HIPAA rule 45 CFR 164.501, All Together LBA PLLC affords special protection to all behavioral session notes. These session notes include parent training, individualized sessions with your child and behavior technician directed session.

It is the policy of All Together LBA PLLC to obtain written authorization through the “Consent for Secure/Release of Information” form prior to disclosing your PHI to any person or entity for purpose other than treatment. You may revoke your authorization at any time, except to the extent that we have already acted upon it. Such authorization expires after a period of one year.

All Together LBA PLLC may use your PHI without authorization for:

• Treatment (To share information with other providers involved in your care)

• Payment (To a third-party billing company, pursuant to HIPAA compliant Business

  Associate Agreement, or the State Department of Administrative Services to bill for your

  healthcare services

• Reminding you of your appointment with All Together LBA PLLC​

Other permitted disclosures of your PHI might include the following:

• Disclosures by law (Department of Children and Families when a law requires that All Together LBA PLLC suspects abuse or neglect)

• Public Health (Mandated reporting of diseases, injury or vital statistics)

• To avert a serious threat to the health and/or safety of you and/or others

• In response to a court order

• If deceased, limited information to coroners, medical examiners or funeral directors

You have the Right to:

• Inspect and copy your medical records by written request within a reasonable timeframe

• Request restrictions on certain uses and disclosure of your PHI

• Receive reasonable confidential communication of PHI

• Submit a written request to amend your medical records, which request must specify

  which portion of the record you wish to amend and how. All Together LBA PLLC reserves the right to deny the request in its sole discretion.

• Receive and accounting of this disclosure for your PHI for seven years prior to your

  request.

• Receive a paper copy of this notice.

How you can report a problem:

If you have any concern about All Together LBA PLLC’s efforts to ensure your private please speak with Joseph Pannozzo, 203-317-9315. If you feel your privacy rights have been violated you have the right to file a written complaint with the U.S. Department of Health and Human Services office for Civil Rights either by visiting: http://ocrportal.hhs.gov/ocr/smartscreen/main/jsf by contacting OCRComplaint@hhs.gov or by writing to Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Ave, S.W. Room 509F, HH Bldg, Washington D.C., 20201

Please initial each item to indicate your understanding and agreement

ALL TOGETHER LBA PLLC

Dear Client ("You"),

All Together LBA PLLC would like to extend its appreciation for the opportunity to work with you and your family. In order to facilitate our cooperation and understanding All Together LBA PLLC would like to advise you as to your right of consent to treatment and highlight our administrative policies for your review and agreement. All Together LBA PLLC will complete formalized, criterion-based assessments to determine a hypothesis for the function of behavior being exhibited. These assessments may include:

• Functional Behavior Assessment

• Assessment for Functional Life Skills

• VB-MAPP

• ABLLS-R

Your consent is deemed to be given and effective by your signature at the end of this form and will remain in effect until and unless revoked in writing at a later date.

Policies of All Together LBA PLLC

• You are responsible for setting and keeping scheduled appointments

• Payment is rendered for services at the time of service.

• You are responsible for understanding your insurance benefits. All Together LBA PLLC will

  verify your benefits prior to our initial session; however, the information provided to you is not guaranteed to be accurate. If there are any changes to your insurance, you are responsible for providing All Together LBA PLLC with advance notice. If you miss three of your scheduled appointments and All Together LBA PLLC does speak with you within 30 days of your last appointment your file may be closed. You will be required to complete a new intake to restart services.

• You hereby authorize All Together LBA PLLC to file any claims for payment of any portion of bills for treatment as may be necessary and assign all rights and benefits to All Together LBA PLLC, therefore. You further agree, subject to state and federal law, to pay all costs, attorney fees, expenses and interest in the event that All Together LBA PLLC takes action to collect payment for services because of your failure to pay all in current charges in full.

• You are required to attend all sessions, with active participation in 50% of the session.

• All Together LBA PLLC will assist in obtaining referrals as required for less intensive

  services and connection to social service agencies to assist in treatment options and support

  (i.e. neurological, primary care, psychiatric, psychological).

• Discharge may occur per family’s request or mastery of treatment goals. All Together LBA

  PLLC will provide at minimum a 30 day transition period upon mastery of treatment goal discharge.

By signing below, you agree that you have read, understand and hereby agree to the above polices and accept responsibility for your account. Further you consent to treatment by All Together LBA PLLC for child identified in the registration packet. You agree that you have the legal right to consent to your child’s treatment and assessment without the consent of any other individuals. As stated above, this consent shall remain effective until and unless revoked in writing at a later date

ALL TOGETHER LBA PLLC

CONSENT FOR TELEMENTAL HEALTH SERVICES

This form is to be used as a supplement to the signed service agreement and treatment consent form that is required for all clients receiving services from All Together LBA PLLC

What is Telemental Healthcare?

Telemental Health Care is a subset of telehealth services that uses online, interactive videoconferencing software to provide behavioral services from a distance. Telehealth does not include the use of fax, audio only, email or video telephone produces like FaceTime and Skype

​

What are the Potential Risks of Telemental Health?

• Technological failures such as unclear video, loss of sound, poor internet connection or loss of internet connection

• Nonverbal cues might be more difficult to observe and interpret during clinician and client interactions.

• May electronically share and sign practice and consent forms and accept risks that come with transmitting information and documents over the internet.

  What are the Benefits of Telemental Health?

• Less limited by geographical location and transportation concerns. Decrease in travel time and ability to meet virtually during inclement weather conditions, national/global crises.

• Ability to participate in treatment from your own home or other environments where you feel safe, secure and comfortable.

• Ability to participate in treatment from your home or other environment when physical needs/disabilities may prevent you from coming to the office.​

Eligibility:

All Together LBA PLLC specifically, Joseph Pannozzo is able to provide Telemental health services to clients located in New York where he is licensed. Clients must provide a valid ID or other proof of residency before Telemental Health sessions can begin. Telemental health may not be the most effective form of treatment for certain individuals or presenting problems. If it is believed the client would benefit from another form of services (Face to Face) or another provider, an appropriate recommendation will be made.

Privacy and Confidentiality

The current laws that protect privacy and confidentiality also apply to Telemental health services. Exceptions to confidentiality are described in Privacy Practices. All existing laws regarding client access to behavioral services and copies of behavioral records apply. Telemental health services are provided through the HIPAA compliant security software.

Client Expectations During Telemental Health Sessions:

You will need the following to join a Telemental Health session:

• A computer, tablet, or phone (no applications or software is required to be downloaded)

• An external or integrated Webcam

• An external or integrated microphone

• An internet connection with a bandwidth of at least 10 MBPS. An ethernet cable over

  WIFI when possible to ensure you receive the best possible connection through your

  internet provider.

• It may be helpful to shutdown all background applications to ensure your session receives

  the majority of the bandwidth, especially application that you use with your camera.

• Access to Google Chrome, Mozilla, Firefox or Safari web browsers

• Proper lighting and seating to ensure a clear image of each participant’s face

• Only agreed upon participants will be present and the presence of individuals unapproved

  by both parties will be cause for termination of the session.

• Client must disclose the physical address of their location at the start of the session.

  Unknown locations will be cause for termination of the session.

• Client shall provide a phone number where they can be reached in the event of service disruption.​

Emergency Protocol:

• Client is to provide the name and contact information for a local emergency contact. In the case of a behavioral health emergency during a Telemental Health Session, where a client is deemed at imminent risk of harming themselves or someone else, the clinician engaged in the session will contact the client’s local emergency services or 911. Release of information forms will be completed for necessary entities unless confidentiality must be breached to protect the safety of the client or other identified individual.

Insurance Self Pay Rates and Payment Procedures:

Prior to starting Telemental Health Services, All Together LBA PLLC will verify your insurance company is approving Telemental Health Services

Consent for Telemental Health Treatment:

I hereby consent to engage in Telemental Health Services with All Together LBA PLLC. I understand that Telemental Health Services includes parent training and direction and observation by a Licensed Behavior Analyst. This also includes assessment and observation. I have the right to withhold or withdraw consent at anytime without affecting my right to future care or treatment.