PRE-SCREENING CHECKLIST Please provide the following information and mail, email or fax to: Positive Synergy Corp. 45 Spring Hill Ave. Northbridge, MA 01534 Email: intake@positivesynergyasd.org Fax: (508)-401-2696 If you have any questions, please call us at: (774)-298-1054 Current letter from doctor stating diagnosis and recommendation for home-based services. (Cannot be more than six months old) I.E.P. Copies of insurance cards (front and back). Pre-authorization is usually required for most insurances. Release for intent of services for insurance company (Attached) Pre-authorization form (Attached) Pre-screening, Intake and Pre-treatment time line Pre-authorization- The pre-treatment process is designed to be a comprehensive evaluation to ensure that your child's need are met once service in the home have been initiated. Before the pre-treatment process can occur pre-authorization for evaluations must be approved by the insurance company. In-home intake process- Once we receive approval, a BCBA will contact you to set up a time to meet in order to complete the intake process. The intake usually takes one to two hours. During this time you will have the opportunity to express your specific concerns and goals for ABA therapy. Parents should have the intake packet completed and any other documentation you would like to share with the BCBA. Pre-treatment- After the intake process is complete, the pre-treatment process will be initiated. Your child will be assessed using a formal tool such as the ABLLS or VB-MAPP. The BCBA will observe and interact with your child weekly to assess their current skill level. This information is used in conjunction with the information gathered during the intake process to develop a treatment plan for your child. Development of treatment plan and programs- After the pre-treatment process is complete, the BCBA will review the information gathered and create a treatment plan for your child. The treatment plan will outline the treatment goals that will be worked during ABA therapy. During this time, the number of ABA therapy hours appropriate for your child will be discussed. After the treatment plan is complete, it is then submitted to the insurance company for approval. This could take 3 weeks. Treatment plan and meeting with therapist- Once the treatment plan has been approved, the BCBA will develop a program binder containing treatment plane and programs for each treatment goal. The BCBA will, then, setup a meeting to review the documents and to have your child meet their ABA therapist. Services will begin with ABA therapist following this meeting. 1
Insurance Reimbursement Form Date: Client s Name: D.O.B Insured s Information: (Primary) Name: D.O.B M F Insurance Company: Phone#: Identification Number: Group/Plan Number: Employer: Insured s Phone #: Insured s Email: Spoke to: Insured s Information: (Secondary, if available) Name: D.O.B M F Insurance Company: Phone#: Identification Number: Group/Plan Number: Employer: Insured s Phone #: Insured s Email: Spoke to: *Please provide us with a copy of the front and back of your insurance identification card. Insurance Verification (For Office Use Only) Primary Insurance Deductible: Individ. $ /Fam. $ Amount Met: Individ. $ /Fam.$ Co-Pay: $ Co-insurance: % Lifetime Max: $ Does treatment need to be pre-certified? Secondary Insurance Deductible: Individ. $ /Fam. $ Amount Met: Individ. $ /Fam.$ Co-Pay: $ Co-insurance: % Lifetime Max: $ Is Co-Pay covered: Other: # of ABA Units: # of ABA Units Used: Covered Dx Codes: Exceptions: Verified by: Date: Clinician referred to case: This form has been designed to provide essential information before your initial intake and assessment in order to make the most productive and efficient use of time. Please use additional pages if necessary. Once pre-authorization has been verified with your insurance company, a board certified behavior analyst will be contacting you to set up an initial intake time. 2
PRE-AUTHORIZATION FORM (PLEASE PRINT) Person Completing this form: Relationship to Child: Child s Name: D.O.B. M F Nickname or name child routinely goes by: Home Address: Street City State Zip Parent/Guardian Home # Work # Cell Email Mother Father Caregiver Contact Information: Name: Cell: Primary Physician: Phone: Fax: Referring Physician: Phone: Fax: FAMILY INFORMATION Mother s Name: Age: Father s Name: Age: Occupation: Occupation: Parents are: Married Divorced Separated Widowed Single If divorced, who has physical custody? Is it full or joint? Who has legal custody? Is it full or joint? Is this Child: Your Biological Child Step Child Adopted Child Foster Child Persons living in the home: 3
MEDICAL HISTORY Please list all of child's current diagnosis: Is your child currently in good health? YES NO If no, please explain: Is your child taking any medications? (Please list): Do you have concerns regarding your child s hearing/vision? Please list any allergies your child has: Other medical conditions/information: EDUCATIONAL HISTORY School Name: System: Grade: Current Teacher(s): Does your child s teacher have concerns about him/her?: Please list special education services your child receives (IEP/504/behavior plan): 4
Authorization for Release of Information Member s Name Birth Date Member s ID# SSN Chart # Street Address City State Zip Code I understand that this authorization is voluntary. I understand that my health information may be protected by the Federal Rules for Privacy of Individually Identifiable Health Information (Title 45 of the Code of Federal regulations, Parts 160 and 164), the Federal Rules fro Confidentiality of Alcohol and Drug Abuse Patient Records (Title 42 of the Cod of federal Regulations, Chapter 1, Part 2), and/or state laws. I understand that my health information may be subject to redisclosure by the recipient and that if the organization or person authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by the Federal privacy regulations. I understand that my records may contain information regarding my mental health, substance use or dependency, or sexuality, and also may contain confidential HIV/AIDS related information. I further understand that by signing below, I am authorizing the release of or exchange of these records to the parties named below. I also understand that my health plan may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this form, except for certain eligibility or enrollment determinations prior to my enrollment in its health plan, and for health care that is solely for the purpose of creating protected health information for disclosure to a third party I understand that I may revoke this authorization at any time by notifying POSITIVE SYNERGY CORP. in writing, but if I do, it will not have any effect on any actions POSITIVE SYNERGY CORP. took before it received the revocation. I hereby authorize POSITIVE SYNERGY CORP. to (check all that apply): Exchange with Release to Obtain from the parties I have indicated below I hereby authorize POSITIVE SYNERGY CORP. to exchange/release/obtain information: verbally only in written form only both verbally and in writing Insurance company receiving/communicating the information: (If secondary insurance is applicable, please provide their information) Name: Address: City: State: Zip: Phone Name: Address: City: State: Zip: Phone 5
Authorization for Release of Information Description of individually identifiable health information (check appropriate types(s) of information s) to be released/exchanged/obtained: All Treatment Plan(s) Claims Outpatient Progress Reports Eligibility/Benefits Attendance Only Clinical records used to make benefit determinations (may include HIV/AIDS and/or Substance Abuse information) All records relating to a Disability claim All pertinent documentation POSITIVE SYNERGY CORP. deems appropriate for the purpose(s) checked below Other (describe): The purpose of this release is (check all that apply): To allow the clinically appropriate management and coordination of the Member s mental health and/or substance abuse treatment and/or coverage under the Member s health benefit plan (Care Management and Coordination). Benefit Management Administration of a Disability claim Claims Administration/Payment Subpoena or other legal process Administration of a Worker s Compensation claim Employer Mandated Treatment referral To Release physical records described above Other (describe): THE MEMBER OR THE MEMBERS S REPRESENTATIVE MUST READ AND SIGN OR INITIAL THE FOLLOWING STATEMENTS: I understand that this authorization will expire: On: (MM/DD/YYYY) or one year from the date of the signature below (or as set forth by other applicable federal or state law see below) (Form must be completed before signing) Signature of Member/Legal Guardian or Member s Representative Signature of Minor Member Date Print name of Member/Legal Guardian or Member s Representative Relationship to the Member Description of Representative s Authority YOU MAY REFUSE TO SIGN THIS AUTHORIZATION 6