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1
603-792-0077(Manchester phone)
603-622-8183 (Manchester fax)
readysetconnect.org
facebook.com/readysetconnect
M
anchester Clinic
Dear Parent:
Thank you for your interest in obtaining services through Crotched Mountain’s Ready Set
Connect program. We are excited for you to join us! Enclosed is a questionnaire and record
releases. If possible, please include a copy of your insurance card(s) when returning the forms.
It is extremely important that each one of these forms is
filled out as completely as possible and mailed back to us
before your appointment date; this includes personal and
insurance information, as well as any required signatures.
If you have any questions or concerns, please call us at 603-792-0077. Again, thank you for your
interest. We look forward to receiving your intake information and meeting here with you at the
clinic.
Ready Set Connect- Manchester
470 Pine Street
Manchester, NH 03104
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Checklist for First Visit
Please complete the following steps prior to your child’s visit
Intake form
• Contact and insurance information. Please fill out completely, sign and date.
Releases
• Complete “Authorization to Exchange Information” sign and date.
• Photo Release: sign and date
• Privacy Notice: sign and date
• Peanut Allergen Policy: sign and date
• Complete “Client Emergency Notification/Health Form”
• Parent Role in Treatment: sign and date
• Complete Credit Card Authorization (if applicable)
Referral and other documentation
• Insurance companies require a letter from your child’s physician stating he/she has an
autism diagnosis and ABA is medically necessary
• A diagnostic evaluation from your child’s physician
Insurance authorization
• Is the service requested covered by your plan? Call your insurance carrier to find out.
There may be co-pays or coinsurance you are responsible for.
Insurance cards
• Please bring all current insurance cards with you to the clinic
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Tips for a Great Ready Set Connect Experience
Attendance
In order for us to provide the very finest therapeutic experience for your child, we ask for
families to ensure that attendance is regular. If you have to cancel a session, please let us know
as soon as you can when you have a cancellation so we can adjust our schedule.
If attendance becomes an ongoing challenge, we will set up a meeting between you and your
BCBA to discuss a plan that works going forward. Ready Set Connect serves many children and
a dependable schedule is vital for our therapists to provide as much service to as many families
as possible.
For cancellations, please contact your child’s Site Director or Scheduler:
Britney Therrien
Site Director
Britney.Therrien@crotchedmountain.org
603-792-0077
Kali McKenna
Scheduler
Kali.McKenna@crotchedmountain.org
603-792-0077
Parent Involvement
A central aspect of Ready Set Connect’s approach is a close partnership with the child’s family.
As our goal is to help our children gain the skills that will translate into success outside of our
clinic, we place immense value on an ongoing relationship with parents. We offer regular
trainings and monthly clinic meetings with your child’s BCBA, where you will get updates on
progress as well as helpful tips and tactics that you can use at home. These opportunities for
engagement are critical in your child’s future success!
Do not forget the Supplies!
Please remember to keep your child’s backpack filled with all necessary daily supplies like
diapers, wipes, a clean change of clothes, snacks, or any other items you may have discussed
with your BCBA.
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Ready Set Connect: Contact and Insurance Information
Personal contact information
Guardian/Parent contact (1) (If applicable)
Client’s name
Guardian/parent’s name
Date of birth (Month/Day/Year)
M
F
Relationship to Client
Street address
Street address [if different from client’s address]
Street address 2
Street address 2
City/state/zip
City/State/Zip
Day telephone
Day phone number
Evening telephone
Evening phone number
E-mail address
E-mail address
Guardian/Parent contact (2) (If applicable)
Second guardian name
Street address [if different from above]
Street address 2
City/state/zip
Emergency contact information
Emergency contact
Day phone number
Evening phone number
Cell phone number
Referring sources
Insurance authorization and billing procedures oblige us to send a copy of clinic reports to the primary care physician, or to the
physician who referred you or your child for services. We endorse this practice, which facilitates continuity of care. Please
indicate which physician should receive a copy of clinic reports.
Primary care physician name
Other referring physician name
Street address
Street address
City/state/zip
City/state/zip
Phone number
Phone number
Is this the physician who should receive a
copy of the clinic reports? yes no
Is this the physician who should receive a copy
of the clinic reports? yes no
Referring Diagnosis:
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Insurance company information
Primary insurance company name
Insurance company address
Insurance company phone number
Policy Holder’s name
Policy Holder’s birth date
Policy Holder’s social security number
Policy Holder’s employer’s name
Identification number:
Prefix:
Certificate number:
Suffix
Prefix
Certificate number
Suffix
Group number
Telephone message policy
We will leave messages at the telephone
numbers listed unless otherwise indicated. All messages respect your confidentiality.
Payment information and policy
You have the option of paying for the clinic visit privately, or procuring payment through your insurance carrier (when applicable). Not all of the
services offered by our clinic are covered by all insurance plans. It is your responsibility to assure that your plan covers the service that you have
requested. We will be contacting your insurance carrier to verify your coverage.
Signature section.
Your signature is required for the reasons explained in the three paragraphs that follow. Please read these paragraphs, and sign on the line at
the bottom if you agree to these conditions. Please do not hesitate to contact us with any questions or concerns you may have about this section.
1. Authorization o
f release of information
I authorize the Crotched Mountain ABA services to send a copy of any report to the primary care physician, and/or to the referring
physician, as indicated on the reverse side of this page.
2. Authorization to be treated for assessment and treatment
I agree to be evaluated and treated, or to have my child/dependent for assessment and treatment, by an ABA Therapist. I understand that I
can revoke this agreement at any time.
3. Assuring payment through your insurance plan
I hereby assign all medical benefits to which I am entitled and authorize and direct my insurance carrier(s) to issue payment of medical
benefits directly to Crotched Mountain Rehabilitation Center for medical services rendered to my dependents or me. I hereby authorize
the release of any medical information necessary to process insurance claims for medical services rendered to me or my dependents. I
understand that I am responsible for all copays, coinsurances, non-covered services, cancellations, and appointments that are not
honored by my insurance company or any other party. If an unpaid balance of $500 is accrued, services will be placed on hold until the
balance is paid in full.
4. In the event of an emergency requiring hospital treatment, every effort will be made to contact parents (person
otherwise designated) before any action is taken. Please note that children will be taken to the closest hospital
in the event of an emergency.
Cancellation and No-Show Policy: Appointments must be canceled a minimum of 24 hours in advance. I understand if I fail to
cancel an appointment without sufficient notice or if I fail to show up for a scheduled appointment, I will be charged $15.00 for the
first occurrence, $20.00 for the second occurrence, and 25.00 for the third occurrence.
Signed:___________________________________________________________Date:__________________
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Ready Set Connect: General Medical Information for Children
The main concerns that I have about my child are:
1.
2.
3.
Concerns that other people (doctors, teachers, family members) have about my child are:
1.
2.
3.
PAST MEDICAL, DEVELOPMENTAL, OR MENTAL HEALTH DIAGNOSES:
List any diagnoses your child may already have, or diagnoses you think your child might have
Diagnosis
When was
diagnosis
made?
Who made the
diagnosis?
Do you agree
with this
diagnosis?
(Circle one)
Comments
Y N
Maybe
Y N
Maybe
Y N
Maybe
MEDICATIONS
List any medications taken by your child. Include dose and frequency if possible:
1.
2.
3.
4.
ALLERGIES
List any allergies your child may have
1.
2.
3.
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Ready Set Connect: Family History
Primary language spoken in the home:__________________________________________________
Secondary language (if any): _________________________________________________________
Is this child adopted?………
Y N
If yes, at what age?
Is this a foster child?……….
Y N
If yes, for how long?
Does anyone in the child’s family have any of the following conditions?
This section refers to biological family members (blood relatives)
Diagnosis
Which family member has this diagnosis?
Learning disability
Attention deficit disorder
Autism or PDD
Intellectual or Developmental
Disorder
Cerebral palsy
Birth defect
Epilepsy
Chromosomal abnormality
Vision impairment
Other developmental disability
Depression
Psychosis
Bipolar disorder
Anxiety
Any Chronic Infectious disease
CHILD CARE
Type of child care
Number of hours per week
Number of other
children at child care
site
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Ready Set Connect: Educational and Therapeutic Services for Children
Early Intervention services
# hours/
week
Comments
Home visitor
Center-based individual visit
Child play group
Parent support/information group
Other (please describe)
Therapeutic Services:
# Hours/
week
Site of
therapy
Comments
Individual speech therapy
Group speech therapy
Occupational therapy
Physical therapy
Counseling or psychotherapy
Social skills group
Other therapies (please describe)
School program
#hours/week
Any comments or concerns?
Regular education setting
Resource room
Special education setting
School contact information
School name
School street address
City/State/zip
Phone number
Teacher’s name
Name of other contact person who knows your child
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Privacy Notice
Effective April 14, 2003
This document is available in an alternative format upon request.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Please read and return to Ready Set Connect - a signed copy of page 3.
Your signature is required before services can be initiated.
Ready Set Connect respects your right to privacy, especially related to your personal health information. To ensure
your privacy, all employees, contracted providers, volunteers, and companies performing business functions for
Ready Set Connect will treat personal and identifiable health information with the utmost confidentiality. Ready Set
Connect is required by law to maintain the privacy of your health information, to follow the terms of this Notice, and
to inform you of our legal duties and privacy practices with respect to your health information.
How Ready Set Connect May Use or Disclose Your Health Information
1. Ready Set Connect will need to utilize and release personal health information for treatment, payment and
healthcare operations. A) Treatment - We will use your health information to provide the evaluation and
consultation services you have requested. We may disclose your health information to Ready Set Connect
therapists and other persons involved in providing or coordinating your services. B) Payment - We may use and
disclose your health information so that your assistive technology services may be billed to, and payment may be
collected from, you, an insurance company or a third party. C) Healthcare Operations - We may use and/or
disclose health information in connection with our own quality assessment activities and for training and
supervision of staff members.
2. We will share your protected health information with third party "business associates" performing various
activities that are essential to the operations of our organization. The release of confidential information to
business associates will occur only when necessary to provide the services you requested or to process essential
functions such as billing, accounting, quality assurance, or legal and financial activities.
3. The staff of Ready Set Connect may use confidential information to provide you with appointment reminders or
information related to treatment alternatives. Additional activities may include the assessment and design of
program activities and/or to generate informational mailings. A consumer may request to be removed from the
Ready Set Connect mailing list by simply calling the privacy officer at 800.932.5837.
4. We will disclose health information about you when required by federal, state or local law.
5. We may disclose health information relative to adverse events with respect to product and product defects, or
post marketing surveillance information to enable product recalls, repairs, or replacement
6. As required by law, we may disclose your health information to public health or legal authorities charged with
preventing or controlling disease, injury, or disability.
7. We may disclose protected health information in the course of any judicial or administrative proceeding, in
response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized),
and, in certain situations, in response to a subpoena, discovery request or other lawful process.
8. We may disclose health information for the following specific government functions: a) health information of
military personnel, as required by military command authorities; b) health information of inmates, to a
correctional institution or law enforcement official; and c) in response to a request from law enforcement, if
certain conditions are satisfied.
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Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization,
unless otherwise permitted or required by law as described in this Notice. You may revoke this authorization, at any
time, in writing, except to the extent that we have already relied upon your authorization in making a disclosure.
How We Will Protect Your Personal Health Information
1. Strict policies and procedures related to privacy will be followed when using computerized information,
electronic mail, facsimile transmissions, voice mail as well as the storage of confidential records.
2. To protect personal health information from unauthorized or accidental release policies dictate the following:
a. Your written consent or that of your legal representative (only) is required to release information to anyone
not otherwise authorized by law to receive it.
b. Requests for information related to mental illness, substance abuse, genetic testing results, HIV, or AIDS
cannot and will not be released or re-released without a written consent from you or your legal
representative.
c. Our Business Associates, who receive protected health information, will be required to sign a Business
Associates Agreement, which obligates them to follow procedures necessary to protect confidential
identifiable health information and to use the information only for the stated purpose identified in the
agreement.
Your Rights Regarding Your Health Information
1. You and/or your legal representatives may review the contents of your chart and obtain a copy (for a fee) after a
written request is submitted. All reviews of a consumer's chart will be conducted in the presence of a Ready Set
Connect staff person.
2. You are entitled to receive confidential communications of your protected health information by alternative
means or at alternative locations. Please call the privacy officer to make such a request.
3. You and/or your legal representative may submit a written request to amend your protected health information
to correct an inaccuracy or to improve clarity. All requests will be processed according to the organization's
policies and procedures. Please note that Ready Set Connect is not obligated to agree to the requested
amendment, but we are required to consider the request and inform you of our decision.
4. You and/or your legal representatives may obtain the disclosure history of your personal health information.
5. You and/or your legal representative may request, in writing, to restrict disclosures of personal health
information, although Ready Set Connect is not obligated to agree to a requested restriction. We are however
required to consider the request and inform you of our decision.
6. If you believe that your privacy rights have been violated, you may file a complaint with our Privacy Officer or
with the Secretary of the United States Department of Health and Human Services. We will not retaliate against
you for filing a complaint.
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Direct Complaints Regarding the Violation of Privacy Rights to:
Privacy Officer – Ready Set Connect
-or-
Secretary of the United States - Department of Health and Human Services
This Notice was published and became effective April 14, 2003
Ready Set Connect reserves the right to amend this Notice.
All changes will be made known to you via a revised Notice.
Ready Set Connect
Use and Disclosure of Information
I certify that I have received a copy of the Privacy Notice, dated April 14, 2003
Consumer:
Date:
OR
Legal Representative:
Date:
TO ENSURE THE TIMELY DELIVERY OF SERVICES THIS PAGE SHOULD BE SIGNED
AND RETURNED TO READY SET CONNECT AS SOON AS POSSIBLE
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Physician Sample Letter for Insurance Authorization
PLEASE NOTE: THIS IS A SAMPLE ONLY. THE PHYSICIAN’S LETTER MUST BE
WRITTEN ON THE PHYSICIAN’S OFFICIAL LETTERHEAD
To Whom It May Concern:
I am a pediatrician (___________) who has provided care to __________from 20____ to
present. __________was diagnosed as autistic in early childhood. He/she currently meets the
diagnostic criteria for autistic disorder 299.00. Specifically she shows (A.1) marked impairment
in the use of nonverbal behaviors, (A.2) failure to develop peer relationships, (A.3) lack of
spontaneous seeking to share interests, (A.4) lack of social or emotional reciprocity as well as,
(B.1) delay in development of spoken language, (B.3) stereotyped and repetitive use of language,
(B.4) lack of social imitative play, and (C.2) inflexible adherence to routines or rituals, and (C.3)
stereotyped and repetitive motor mannerisms.
Applied Behavioral Analysis (ABA) is the best-established most evidence-based approach for
the treatment of autism spectrum disorders. An intensive ABA program is medically necessary
for the treatment of autism because its effectiveness has been clearly established through well-
controlled scientific studies. Research has shown that ABA therapy helps to address the
behaviors, speech/language/communication impairments, and social difficulties that children
with autism spectrum disorders exhibit.
Therefore, intensive ABA therapy services are medically necessary for____________ to
ameliorate __________’s condition of autism by improving his/her functional level.
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Pick Up Authorization
Child’s Name: __________________________________________________
The following people are authorized to pick up my child:
Name: _____________________________ Relation: __________________________ Phone: _____________________
Name: _____________________________ Relation: __________________________ Phone: _____________________
Name: _____________________________ Relation: __________________________ Phone: _____________________
Name: _____________________________ Relation: __________________________ Phone: _____________________
Name: _____________________________ Relation: __________________________ Phone: _____________________
Parent Signature: ______________________________________________ Date: ______________________
*Your child wil be released only to those persons listed on your authorization form. Please advise family and
friends who occasionally pick-up that identification will be required. Please notify the office if there are any
changes in pick-up plans or arrangements or changes on the authorization form.
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Authorization to Exchange Information
Client’s Name:_____________________________________________
I request and authorize Ready Set Connect to exchange information with the personnel of:
Name
: ___________________________ Title/Relation:_______________________________________________
Name: ___________________________ Title/Relation:_______________________________________________
Name: ___________________________ Title/Relation:_______________________________________________
Name: ___________________________ Title/Relation:_______________________________________________
Parent Signature: _________________________________________________ Date:_________________
*If you would like to authorize communication with specific individuals outside of Ready Set Connect, please
list them above. (ex, your child’s teacher, speech therapist etc.)
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Nut Allergen Policy
Dear Parents and Guardians,
Multiple children at Ready Set Connect have severe food allergies to various kinds of nuts. We
are asking your help to provide all children with a safe environment here at Ready Set Connect.
To reduce the chance of an allergic reaction, we ask that you do not send any nut products to
Ready Set Connect in a snack or a lunch. If your child has eaten any form of nuts before coming
to Ready Set Connect, please be sure that your child’s hands and face are thoroughly washed
before coming into the Clinic. It is important that there is strict avoidance of this food in order to
prevent a life-threatening allergic reaction.
Thank you in advance for your cooperation! Please fill out the bottom section of this form and
return it to Ready Set Connect with your child.
I have read and understand the nut free procedures for Ready Set Connect and I agree to
do my part in keeping Ready Set Connect nut free.
Child’s Name ________________________________________________________________
Parent’s Signature _____________________________________ Date __________________
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Ready Set Connect: Necessary Items
1.) Extra pairs of clothing - This includes:
- Pants
- Shirt(s)
- Underwear
- Socks
***Even if children are toilet trained we like to keep an extra pair of clothing in preparation of
minor spills or messes from sensory activities! We ask that the clothing sent in is appropriate for
the season and with labels on the tags with your child’s name/initials.
2.) Supply of bathroom materials – This includes:
- Extra underwear (if child is toilet training)
- Supply of pull ups/diapers for the day
- Package of wipes
***If you prefer to send in daily supplies of diapers and wipes just let us know and we will keep
everything with the child’s backpack.
3.) Lunchbox with snacks and lunch (if applicable to schedule)
with water bottle or sippy cup
***We kindly ask that labels are placed on your child’s belongings (including lunchboxes and
cups) since it is not uncommon for us to have duplicates! Reminder: RSC is a NUT-FREE
facility!
4.) AAC Device Accessories – Charging Cables
***If your child utilizes an AAC device, we ask that you send in any charging cables that
may be used to ensure that we can utilize it during your child’s session with us!
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Weather Cancellation Procedure at Ready Set Connect
Dear Parents and Guardians,
As the weather starts to change, we want to remind everyone of our snow and inclement weather policy.
We want to ensure the safety of our families and staff at all times.
In the event of inclement weather, please look for cancellation or delayed opening on WMUR at
wmur.com. When there is a change in the services at our Concord office, the website will list our
clinic as ‘Ready Set Connect Manchester.’
Other Important Information:
• A 2-hour delay means the clinic will open at 11:00 a.m.
• On the WMUR website or app the notification appears with the “school” cancellations, but on the
WMUR TV station the notification appears with the “business closures”
• If you need to cancel due to inclement weather, please call and leave a message as early as
possible or email both the scheduler kali.mckenna@crotchedmountain.org and the Site
Director brittney.therrien@crotchedmountain.org. This helps us to schedule therapists and
children accordingly for the rest of the day.
If you have any questions do not hesitate to call the Manchester office at 603-792-0077.
Thank You,
Ready Set Connect
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Ready Set Connect: Client Emergency Notification/Health Information
PARENT OR LEGAL GUARDIAN TO COMPLETE. Please help us to ensure that your child’s health care needs are met by
completing this form. This enables the school nurse to individualize a plan of care based on your child’s specific needs and provides us with
important emergency contact information.
Student Name: Last First MI
Student’s Date of Birth
Sex Male
Female
Student’s Social security #
Address
City:
State:
Zip Code:
Name of Mother or Legal
Guardian
Home Phone:
Work Phone:
Cell Phone:
Employer:
Name of Father or Legal
Guardian
Home Phone:
Work Phone:
Cell Phone:
Employer:
Name/Address of Pediatrician or Primary Care Provider
Phone #:
Name/Address of Specialist Caring for your Child
Phone #
In case of emergency – if parent/guardian cannot be reached – contact the following:
Name ___________________________________________________________
Relationship____________________________
Phone number(s) Home _______________________ Work __________________________ Other
________________________
PART 2: COMPLETE ALL BOXES THAT APPLY TO YOUR CHILD. Parent/legal guardian is responsible for providing the
school with any medications, special food, or equipment that the student will require during the school day. Contact the school nurse to obtain
specific forms for medication administration and/or procedures.
PRIMARY DIAGNOSES (Please list all diagnoses for which student currently receives medical care)
CURRENT MEDICATIONS (Please include doses, times they are given, and the reason for each)
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ALLERGIES
Allergy type:
Medication(s) (list medications)
Foods (list foods)
Insect stings (list insect(s))
Others (list)
Reactions: (Date of last occurrence if yes)
Coughing (Date: __________) Hives (Date: _________) Rash (Date: ___________)
Difficulty breathing (Date: _________) Local swelling (Date: ________)
Wheezing (Date: ________)
Generalized swelling (Date: _______) Nausea (Date: ___________) Other (Date: _________)
Currently prescribed allergy medications/treatments:
Oral antihistamine (Benadryl, etc.) Epi-Pen
Other _____________________________________
ASTHMA
Triggers: Environmental (i.e.smoke, dust, pets, pollen) Please list: _________________________________
Other ____________________________________________________________________
Symptoms:
Chest tightness, discomfort, pain Difficulty breathing Coughing Wheezing Other _____________
Currently prescribed asthma medications/treatments _________________________________________________
____________________________________________________________________________________________
Does your child have a written Asthma Action Plan? Yes No
SEIZURE DISORDER
Type of Seizure:
Absence (staring, unresponsive) Complex partial Generalized tonic-Clonic (grand mal)
Other (explain/describe)
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OTHER HEALTH ISSUES (i.e. diabetes, gastrointestinal disorders, genetic syndrome)
SPECIAL PROCEDURES required (i.e. oxygen, bladder catheterization, tracheostomy care, suctioning)
Yes No Explain:
BEHAVIORAL CONCERNS (Describe)
SPECIAL DIET REQUIREMENTS
Yes No Explain:
VISION CONCERNS
None
Contacts/glasses ____________________________
Other
HEARING CONCERNS
None
Hearing aid(s) Right Left Both
Other
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SPECIAL SAFETY CONSIDERATIONS (precautions for transfers, feeding, positioning, special safety equipment, etc.)
Yes No Explain:
In the event of an emergency requiring hospital treatment, every effort will be made to contact parents ( person otherwise
designated) before any action is taken. Please note that students will be taken to the closest hospital in the event of an
emergency.
Parent/Guardian Signature ______________________________________________ Date __________________
Part 3: To be completed by school nurse
I have reviewed this student’s health information and initiated an individualized plan of care if indicated.
Notes:
______________________________________________________________________________
_________________________
School Nurse Signature Date
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Privacy Notice
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Ready Set Connect respects your right to privacy, especially related to your personal health information. To ensure
your privacy,
all employees, contracted providers, volunteers, and companies performing business functions for Ready Set
Connect will treat
personal and identifiable health information with the utmost confidentiality. Ready Set Connect is required by law to
maintain the
privacy of your health information, to follow the terms of this Notice , and to inform you of our legal duties and privacy
practices
with respect to your health information.
How Ready Set Connect May Use or Disclose Your Health Information
1. Ready Set Connect will need to utilize and release personal health information for treatment, payment and
healthcare
operations. A) Treatment - We will use your health information to provide the evaluation and consultation services
you
have requested. We may disclose your health information to Ready Set Connect therapists and other persons
involved in
providing or coordinating your services. B) Payment - We may use and disclose your health information so that your
assistive technology services may be billed to, and payment may be collected from you, an insurance company or a
third
party. C) Healthcare Operations - We may use and/or disclose health information in connection with our own quality
assessment activities and for training and supervision of staff members.
2. We will share your protected health information with third party "business associates" performing various activities
that
are essential to the operations of our organization. The release of confidential information to business associates will
occur only when necessary to provide the services you requested or to process essential functions such as billing,
accounting, quality assurance, or legal and financial activities.
3. The staff of Ready Set Connect may use confidential information to provide you with appointment reminders or
information related to treatment alternatives. Additional activities may include the assessment and design of program
activities and/or to generate informational mailings. A consumer may request to be removed from the Ready Set
Connect
mailing list by simply calling the privacy officer at 800.932.5837.
4. We will disclose health information about you when required by federal, state or local law.
5. We may disclose health information relative to adverse events with respect to product and product defects, or post
marketing surveillance information to enable product recalls, repairs, or replacement
6. As required by law, we may disclose your health information to public health or legal authorities charged with
preventing or controlling disease, injury, or disability.
7. We may disclose protected health information in the course of any judicial or administrative proceeding, in
response to
an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), and, in certain
situations, in response to a subpoena, discovery request or other lawful process.
8. We may disclose health information for the following specific government functions: a) health information of military
personnel, as required by military command authorities; b) health information of inmates, to a correctional institution
or
law enforcement official; and c) in response to a request from law enforcement, if certain conditions are satisfied.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization,
unless
otherwise permitted or required by law as described in this Notice. You may revoke this authorization, at any time, in
writing,
except to the extent that we have already relied upon your authorization in making a disclosure.
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IN-PERSON PARENT-FOCUSED ABA TRAINING
Parenting a child with Autism requires much support and
a specialized set of skills. Since all families have unique
needs and preferences, we have developed a variety of
different formats for supporting parents with the skills to
promote the successful development of their child.
Ready Set Connect is now offering the opportunity for
parents to come to one of our centers and to meet with a
BCBA, who will provide instruction on specific ABA
skills and evidence-based practices and curriculum.
Everyone at Ready Set Connect is invested in supporting
each child and helping them thrive in all settings of their
life. Teaching skills that can only be demonstrated in a
clinic setting with staff is not enough for us;. we want to see children generalize what they learn
at Ready Set Connect and apply these skills at home and in the community.
To accomplish this, we want to establish a partnership between our BCBAs and the parents.
Using parent input, Ready Set Connect staff will set goals for what the child can practice at home
and what the parent can do to help. With the help of our training, you and your child will
meet these goals.
We’ll start small with whatever you can manage and then with our support you will find yourself
teaching your child skills you may never thought possible!
Trainings will happen in each of our centers, scheduled at an agreed upon time between families
and the BCBA. We will follow all necessary COVID-19 protocols. Please provide 24 hour notice
by calling or emailing your child’s center if you need to reschedule an appointment.
COVID protocols
● Limited to two outside family members
● Parents must participate in COVID health screening via phone 24 hours before training
and at time of visit
● Masks are mandatory
● Social distance must be maintained
● Entrance through building at designated areas
● Parents will participate in follow up health screenings post visit and report any COVID
related symptoms after the training to the Center Site Coordinator.
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Ready Set Connect
Parent’s Role in Treatment
The importance of parents and guardians at RSC
Parents and guardians are critical members of the treatment team at Ready Set Connect. Their
participation in the treatment process is one of the most important components of a successful
outcome. Our staff’s expertise in Applied Behavior Analysis is simply not enough to insure that your
child receives the best possible treatment. We need your help to make sure your child gets the most
out of their RSC experience. We completely understand that each family’s needs and resources are
different so we create a customized plan for every child and their parents/guardians. There are just a
few simple things that we need your help
How can you assist with your child’s treatment?
Parent - Focused ABA Training- Parenting a child with Autism requires a lot of support and a specialized
set of skills. Since all families have unique needs and preferences, we have developed a variety of
different formats for providing parents with the skills to promote the successful development of their
child. Our clinicians utilize evidence based practices and curriculum to instruct parents in the specific
skills that are required for their child. What we need is a commitment to participate in the scheduled
sessions.
Set Goals for Home: Everyone involved in your child’s treatment is invested in having them thrive in all
settings of their life. Teaching your child skills that they can only demonstrate in our clinic or improving
their behavior only with our staff is just not enough for us. We want them to “generalize” what they
learn at Ready Set Connect to their home and community. To accomplish that, we will set some goals
with you for what your child can practice when they are at home with you. We’ll start small with
whatever you can manage and then with our support you will find yourself teaching your child skills you
may never have thought possible.
Provide us with Information: Data is the cornerstone of Applied Behavior Analysis. We make all of our
treatment decisions based on our rigorous data collection. We also know that many parents want to
know with some certainty how their child is progressing. It is very important for us as well to know how
your child is doing at home. While we don’t expect you to collect data on tablets like we do, we will ask
you to provide us with some manageable information about your child’s progress at home. The same as
your child’s pediatrician will want to know your child’s temperature if they prescribe medication
because of a fever, we’ll want to know objectively how well they are behaving or performing a skill at
home. Additionally it is always helpful when we are made aware of any life changes (e.g., an upcoming
change in residence, someone moving in or out of the house, a family illness or traumatic event). We
may be able to help your child adjust to these life events.
Attendance: Help us with your child’s regular attendance. Our ABA therapists are scheduled such that
your child will receive 1:1 treatment every minute they are scheduled at our clinic. Everyone has a
different definition of “good” attendance. For us, 90% is the attendance standard that we seek to
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maintain. While we know things can occasionally happen, if attendance drops below 90% for a period of
time we will likely be in touch to determine what we can adjust to help it improve. Also, prompt drop
off and pick up according to your child’s schedule is very important for the effective delivery of our
services. If your child is going to be absent, or an emergency requires you to be late either dropping off
or picking up, we ask that you call us. If your child is more than 15 minutes late, we may need to cancel
that session.
I have read and understand the expectations indicated above:
Parent/Guardian
Date
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Credit Card Co-Payment Authorization
I, ____________________________ authorize Ready Set Connect to
charge my credit card with $ __________for my co-payment/ deductible/co-
insurance/cancellation fee for every therapy session provided or cancelled less
than 24 hours in advance to my child ,____________________________.
I understand that it is my responsibility to maintain sufficient funds and to notify
RSC if there is a change to the credit card information on file.
Credit Card Information:
□ VISA □ MC □ AMEX □ DISCOVER
Account Number:
Expiration Date: (Month/Year)
Cardholder’s Name: _________________________
Cardholder’s Signature: ______________________
o VERBAL AUTHORIZATION
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Completed 10 September 2021

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