Consent to Treat/Bill and Privacy Information

Authorized parents or guardians (herein be referred to as “Caregiver(s)”) allow Behavioral Achievements LLC to provide optimal care for their child, bill appropriately, share their information securely, and consent to the following policies and procedures written below.

Consent For Treatment

Caregivers consent to and authorize the provider(s) at Behavioral Achievements LLC to treat their child. Caregivers understand this could include behavioral health and social interaction interventions, parent meetings, supervision, data collection, administration, observations, and other requirements for the administering of behavioral health services. Caregivers further understand that Behavioral Achievements LLC is available to explain the treatment and a Caregiver has a right to refuse treatment on behalf of the child. Caregivers understand that this consent will be valid and remain in effect for as long as their child(ren) attends any generalized setting where staff members of Behavioral Achievements LLC perform behavioral services (at their home, in a clinic, at school, at social gatherings, etc.).

Consent For the Use and Discourse Of Health Information

Caregivers hereby authorize Behavioral Achievements LLC to release any information acquired during their child(ren)’s behavioral services to any authorized agent for the purposes of coordinating healthcare, treatment, and payment. Caregivers authorize the release of medical, and/or behavioral health information to their insurers as necessary for determination and payment of benefits; for utilization review and professional standards review organizations, companies, and community resources that assist with the child(ren)’s healthcare needs.

Notification of Privacy

Behavioral Achievements LLC complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). An authorized Caregiver will have been given and signed the Behavioral Achievements LLC HIPAA Service Agreement and Consent Form during intake on behalf of the child. An updated copy of this notice can be requested in paper by asking individuals at the front desk or is available online at

Consent To Bill, Assignment of Benefits, And Payment

Caregivers authorize Behavioral Achievements LLC to file a claim with their insurance carrier for services rendered. They also authorize payment of benefits directly to Behavioral Achievements LLC for services provided to their child(ren). They further understand that they are responsible for any part of the charges that are not covered/paid by their insurance carrier and may be billed directly for services in the event they fail to provide updated insurance information at the earliest availability to provide notice of changes.

Acknowledgement of Personal Property

Caregivers understand that Behavioral Achievements LLC shall not be liable for loss or damage of any personal property.

Information Exchange

Behavioral Achievements LLC, under the discretion of the child(ren)’s Caregiver, may exchange information relevant to the development of behavioral intervention planning. For each exchange of information, parents are required to complete an AUTHORIZATION TO RELEASE INFORMATION form provided by Behavioral Achievements LLC. This information will help provide a better understanding of issues that can stem from specific displays of behavior(s).

Benefits/Risks of Behavioral Health Treatment

Potential benefits include better relationships, solutions to specific problems, improved understanding of the child, reduction in destructive or violent behaviors, and relief from unpleasant emotions. There may be some risks including, but not limited to, addressing painful emotional experiences, being challenged, or confronted with a particular issue, or being inconvenienced due to the costs of services.

Limits Of Confidentiality

Behavioral Achievements LLC is permitted or required, under specific circumstances, to use or disclose protected health information (PHI) without your written authorization: suicidal urges (a child being a danger to themselves), homicidal urges (being a danger to others), court order/subpoena, and child abuse/neglect.