ADOS Intake Packet

Finance agreement

In accordance with the services that will be provided by Dominion Care, I hereby agree and authorize my insurance company to pay this agency in full for services rendered in accordance with my medical benefits as agreed to in my insurance policy. I hereby authorize Dominion Care, to release to my insurance company any information necessary for seeking reimbursement for the services listed below.

Fee schedule

ADOS Intake Packet

Right to Confidentiality

We take confidentiality very seriously. We follow very strict rules from the United States and State Governments about when we can release your medical record your protected health information. The Federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule establishes a foundation of Federal protection for personal health information, carefully balanced to avoid creating unnecessary barriers to the delivery of quality health care. The Rule generally prohibits this program from using or disclosing your protected health information unless authorized by you, except as follows: First, we are required by law to disclose your protected health information in certain circumstances, for example, to report abuse and neglect, and to warn about dangerous behavior. Second, we are authorized to disclose your protected health information without your consent when we use the information for treatment, payment or the health care operations of the program.

Treatment generally means the provision, coordination, or management of health care and related services among health care providers or by a health care provider with a third party, consultation between health care providers regarding a patient, or the referral of a patient from one health care provider to another.

Payment encompasses the various activities of health care providers to obtain payment or be reimbursed for their services.

Health care operations are certain administrative, financial, legal, and quality improvement activities of a program that are necessary to run its business and to support the core functions of treatment and payment.

The program will, without your authorization:

Use or disclose your protected health information for its own treatment, payment, and health care operations activities.

We may disclose your protected health information for the treatment activities of any health care provider (including providers not covered by the Privacy Rule).

We may disclose your protected health information to another health care provider (including providers not covered by the Privacy Rule) for the payment activities of the entity that receives the information.

We may disclose your protected health information to another provider for certain health care operation activities of the provider that receives the information if:
– Each provider either has or had a relationship with you, and protected health information pertains to the relationship;
– The disclosure is for a quality-related health care operations activity or for the purpose of health care fraud and abuse detection or compliance.

Security.
Your medical record (your protected health information) is kept in a secure location and only those employees or clinicians who need access to your medical record for treatment, payment or health care operations have access to your medical record unless you sign an authorization.
It is our policy to reasonably limit disclosures of, and requests for, protected health information for payment and health care operations to the minimum necessary. We also limit which members of our workforce may have access to protected health information for treatment, payment, and health care operations, based on those who need access to the information to do their jobs. We may also disclose information to contact you, for example to make appointments, to check with you about how you are doing, and to evaluate the services that we provide to you. We may also contact you for our fund-raising efforts.

ADOS Intake Packet

Your right to see your record.

You have the right to see your record, or to receive a summary of your record. To do this, please contact your Service Provider. You also have the right to ask us for an accounting of the persons or programs to whom we have disclosed your protected health information. (This does not include disclosures for treatment, payment, or health care operations, or to persons authorized by you.) To receive this accounting, please contact your Care Provider

If you disagree with the contents of your medical record, you may also request an amendment to your record. We will place that amendment in the medical records unless we did not create that part of the record, or we believe the existing record is accurate and complete. If we grant the amendment, we will notify you and you may request that we provide the amendment to other programs and to programs that you identify to us as having already received your medical record. If we deny the amendment, we will give you specific reasons for the denial. You may then submit a statement of disagreement and we may submit a rebuttal. If you notify us in writing, we will attach your request for amendment and our denial to future disclosures of that part of your medical record. Also, if you continue to disagree, you may file a complaint with the Complaint Officer at (Agency Info) and the Office of Civil Rights at HHS.gov.

How to file a complaint.

If you believe that your protected health information has been released in violation of the law, you have the right to file a complaint. You may file a complaint with our program by contacting or submitted a letter to: Complaint Officer (Agency Info). You may also file a complaint with the Office of Civil Rights at HHS.gov. You have our promise that our program will not retaliate against you if you choose to file a complaint.
If you want to send your protected health information to someone, you must sign an authorization.
Authorizations may be obtained from your Service Provider.

Notification of Breach.

In an event there has been an breach in releasing personal health information (PHI), Dominion Care will provide notice to you by telephone or verbally by Dominion Care. Such conversation shall be documented by Dominion Care.

Public Interactions.

In order to maintain confidentiality for you and your child about the services we provide, I will not approach you if I see you in public. If you approach me, I will know that it’s alright to have an interaction in that setting. Please know that I won’t be able to speak about intervention specifics in a public setting, and that if I am out with my family or friends, I may not be able to have a long interaction.

I have read the above Notice of Privacy Practices and Notification of Breach of the Agency and understand that I may request a copy of this notice at any time.

 
 
 Yes, I have read the above notice.
 
 No, I have not read the above notice.

ADOS Intake Packet

Rights & Responsibilities

Each individual has a right to exercise his legal, civil, and human rights, including constitutional rights, and statutory rights. Each individual has a right to have services that he receives respond to his needs and preferences and be person-centered. Each individual also has the right to be protected, respected, and supported in exercising these rights. Dominion Care will not partially or totally take away or limit these rights solely because an individual has a mental health or substance use disorder or an intellectual disability and is receiving services for these conditions or has any physical or sensory condition that may pose a barrier to communication or mobility.

As an individual being served by Dominion Care you retain all of your rights when you enter this agency for services. You are also protected by the following rights:

1. To not be denied treatment or services on the basis of race, national origin, sex, religion, handicap or sexual orientation
2. To be treated with dignity and respect
3. To be told about your treatment, program services, policies, and rules in writing and in the manner, format, and language you can easily understand.
4. To have a say in your treatment and to help develop your treatment plan.
5. To say what you prefer and be an active participant in your treatment.
6. To be fully informed of treatment involving significant risk
7. To receive services in the least restrictive environment
8. To be informed of other services to which you may be eligible such as educational or vocational services, housing assistance, services, or benefits under Titles II, XVI, XVIII, and XIX of the Social Security Act, United States Veterans Benefits, and services from legal and advocacy agencies.
9. To inspect, copy, and correct your records subject to and in accordance with the provision of Virginia law.
10. To confidential treatment/services and to have information about you maintained in a confidential manner within the limits of the law
11. To speak with others in private
12. To ask questions and be told about your rights.
13. To get help with your rights
14. To have freedom from: Abuse, Exploitation/Misappropriation of Funds, Retaliation, Humiliation, and Neglect

As an organization Dominion Care will:

Dominion Care has policies and procedures governing harm, abuse, neglect, and exploitation of individuals receiving their services which require that, as a condition of employment or volunteering, any employee, volunteer, consultant, or student who knows of or has reason to believe that an individual may have been abused, neglected, or exploited at any location covered by this chapter will immediately report this information directly to the director. The director will immediately take necessary steps to protect the individual until an investigation is complete. This may include the following actions has policies and procedures governing harm, abuse, neglect, and exploitation of individuals receiving their services which require that, as a condition of employment or volunteering, any employee, volunteer, consultant, or student who knows of or has reason to believe that an individual may have been abused, neglected, or exploited at any location covered by this chapter will immediately report this information directly to the director. The director will immediately take necessary steps to protect the individual until an investigation is complete.

ADOS Intake Packet

This may include the following actions:

♦ Direct the employee or employees involved to have no further contact with the individual.
♦ In the case of incidents of peer-on-peer aggression, protect the individuals from the aggressor in accordance with sound therapeutic practice and this chapter.
♦ Temporarily reassign or transfer the employee or employees involved to a position that has no direct contact with individuals receiving services.
♦ Temporarily suspend the involved employee or employees pending completion of an investigation.

Any complaints should be addressed to the Dominion Care ‘Human Rights Director’, Phone Number: 804 285 9838, Address: 1640 E. Parham Rd. Richmond, VA 23228

The Regional Advocate’s role is to help you with the grievance process.

Responsibilities of the primary caregiver or legal guardian and Individual:

1. To keep all scheduled appointments with Dominion Care staff or to inform staff in advance if you are unable to keep the appointment.
2. To work on your service goals as agreed upon in your Individualized Service Plan.
3. To provide staff with accurate and complete information as it pertains to your treatment and care at Dominion Care. To treat all others with respect.
4. To adhere to the Dominion Care rules prohibiting smoking and drug use and banning weapons on the Dominion Care premises.

INQUIRY, APPEAL AND GRIEVANCE PROCEDURES: There is always the potential that the treatment received by an individual may not be perceived by that individual as fair or appropriate. To safeguard against any mistreatment of an individual, or any failure to provide quality care, or inaccurate accounting regarding individual charges, Dominion Care has established a grievance procedure whereby the individual can make their concern known. The basic procedure if you have a complaint or concern is as follows: Individuals who express dissatisfaction will be instructed to talk to clinical or administrative staff regarding their complaint or grievance. Individuals will be asked if they wish to write a formal grievance and they will be assisted by the Program Director or designee. Complaints and grievances will be investigated and resolved within 10 calendar days.

I acknowledge everything listed below:

 
 Yes, I agree.
 
 No, I do not agree.
 
I have received a copy of my rights and they have been both read and explained to me.
I have also been informed of the role of the Regional Advocate and how to contact this person.
I have been informed of the outcome tracking measures utilized by Dominion Care.
I have been made aware of internal complaint and grievance process within Dominion Care.
I am requesting services from Dominion Care.

ADOS Intake Packet

Informed consent

 
I, consent to participate in ADOS services offered and provided by Dominion Care, LLC. I understand that I am agreeing to only those services that the above provider is qualified to provide within:

• 1. The scope of the provider’s license, certification, and training
• 2. The scope of the provider’s license, certification, and training of the mental health provider’s directly supervising the services received by the client

If the client is under the age of 18 or is unable to consent to treatment and/or legally authorized to initiate or consent to treatment on behalf of this client.
 
 

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ADOS Intake Packet

Provider Choice

If you are an individual or an individual’s legal guardian seeking the service listed below, you are entitled to a choice of provider. This means you may select dominion ADOS services as your provider, or you may choose from another provider within the community. In addition, any action taken by this agency may be appealed to the department of medical assistance services (DMAS) by following the procedures listed below.

• The freedom of choice has been discussed with me. I understand that I have the option to receive services from other providers but choose Dominion Care as my provider for the following service: ADOS.
• The freedom of choice has been discussed with me, and I have chosen to receive this service from another provider in the community. I understand that Dominion Care has no obligation to cover the costs of those services.

 
Any action taken by this agency that affects the services of this individual may be appealed to DMAS. Your notification must be written and submitted to the appeals division, department of medical assistance services, 600 east broad street, suite 1300, Richmond, Virginia 23219. The written request for an appeal must be filed within thirty (30) days of this notification. If you file an appeal before the effective date of this action, (date), services may continue during the appeal process. However, if this decision is upheld by the appeals division, you will be required to reimburse the medical assistance program for services provided after (date). For further information on recipient rights, you may call 804-786-7933 or visit them on the website at www.dmas.virginia.gov/.
 
By signing below, I agree that the freedom of choice and the appeals process of the department of medical assistance services has been discussed with me.
 

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ADOS Intake Packet

ADOS Observation and Confidentiality Agreement

Client name:

Birth date:

The privacy of our clients, staff, and families is of paramount importance at Dominion Care. We also value the training and credentialing of mental health professionals in our state. As such, we are happy to offer observation opportunities to outside clinicians who are becoming trained in the ADOS administration. Many of these opportunities are offered through collaboration with the VCU Leadership Education in Neurodevelopmental Disabilities (LEND) program, but other opportunities are permitted to outside providers, with parent permission.

By signing the Observation and Confidentiality Agreement, you are acknowledging:

• Your child’s assessment will be observed be an outside provider who is contracted with Dominion Care to provide consultation in their area of expertise (e.g., Speech Language Pathology, Occupational Therapy) during this assessment.
• Your child’s assessment may observed be an outside clinician who is learning to administer the ADOS.
• Your child’s assessment may observed be a Dominion Care employee from another office or region who is learning to administer the ADOS.

Please note that all mental health providers are governed by the Health Insurance Portability and Accountability Act (HIPPA) which emphasizes confidentiality.

▢ I agree to the above observation.

▢ I do NOT agree to the above-described observation.

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