Further, Pavo Behavioral Therapy will take reasonable steps to ensure that those with Limited English Proficiency (LEP) have meaningful access and equal opportunity to participate in our services, activities, and programs.

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Employees acknowledge the following policies about clients: employees will never disclose or discuss protected health information, client care, programming, client name, etc. with anyone who is not employed by Pavo Behavioral Therapy LLC; employees will take every precaution to ensure that data sheets, log books, or other sensitive documents that could reveal a diagnosis is protected (e.g., in a locked filing cabinet and always on their person when not under lock and key); employees will never communicate or publish protected health information of clients including names and images in physical or electronic form without prior written consent of the client and Pavo Behavioral Therapy.

All records, including but not limited to medical and psychological reports, videotapes, DVDs, photographs, voice recordings, data and information related to the client ("Confidential Information") are the property of Pavo Behavioral Therapy. Team members should not disclose any Confidential Information to any person or use any Confidential Information for the benefit of the team member or any other person, except with the prior written consent of the Pavo Behavioral Therapy.

Due to the sensitive nature of information, it is imperative that Pavo Behavioral Therapy keeps sensitive information confidential. Any information about your children or family will be shared on a "need to know" basis only. Thus, Pavo Behavioral Therapy is very sensitive about discussing your child's developmental needs and your family information in public places. Your client information will not be left unattended at any time (e.g., session notes, data sheets, binders). All devices (e.g., phones, iPads, computers) have auto-lock and password enabled at all times. In the case that a device is missing or stolen, the team member will notify the director immediately. Pavo Behavioral Therapy has the capability of erasing all its electronic devices to avoid a breach of sensitive information. Your client information will not be shared on any forms of social media sites. Emails containing sensitive information sent outside of the Pavo Behavioral Therapy network to authorized professionals will be password protected.

This notice describes how medical/mental health information about you may be used or disclosed and how you can get access to this information. Please review it carefully.

Pavo Behavioral Therapy must to maintain the privacy of your health information and to provide you with this notice. You will be asked to sign a Release of Information Form. Once you have signed the Release of Information Form, Pavo Behavioral Therapy staff members may use or disclose your Protected Health Information (PHI) for purposes of diagnosis, treatment, obtaining payment, or to conduct healthcare operations. For example, to receive payment for our services, Pavo Behavioral Therapy must provide information to the funding source being used.

Other permitted and required uses and disclosures that may be made without your consent, authorization, or opportunity to object:

Abuse or Neglect: If any Pavo Behavioral Therapy member suspects abuse or neglect of a child and elder, he/she is mandated to make a report to the appropriate public authorities.

Danger: If a Pavo Behavioral Therapy staff member suspects that you are in imminent danger of harming yourself or someone else, he/she is mandated to make a report to the person at risk to the public authorities.

Legal Proceedings: Pavo Behavioral Therapy staff members may disclose PHI in response to a court order or subpoena or certain other legal proceedings.

You have the following rights regarding PHI Pavo Behavioral Therapy maintains about you:

Right to Inspect and Copy: You have the right to inspect and request copies of information that may be used to make decisions about your care. Usually, this includes demographic and billing records but does not include case notes. To inspect and receive copies of information, you must submit a request in writing. If you request a copy of the information, Pavo Behavioral Therapy may charge a fee for the cost of copying, mailing, or other supplies associated with your request. Pavo Behavioral Therapy must respond to your request within fifteen days of receipt.

Right to Amend: If you feel that PHI about you is incorrect or incomplete, you may ask Pavo Behavioral Therapy to amend the information. You have a right to request an amendment for as long as Pavo Behavioral Therapy keeps the information. Your request for amendment must be in writing and must provide a reason supporting your request.

Right to an Accounting of Disclosures: You have the right to request an Accounting of Disclosures regarding information that Pavo Behavioral Therapy staff members have made about you. You must submit your request in writing to the above address. Your request must state a period for the disclosures, which may not be longer than six years and may not include dates before June 1, 2022.

Right to Request Restrictions on Uses and Disclosures: You may request that disclosure of confidential information be limited. If Pavo Behavioral Therapy is unable to agree to that restriction, we can discuss other options, such as referral to another counselor. Right to Limit Reception of Confidential Information: For example, you may request that Pavo Behavioral Therapy staff members only contact you at a certain telephone number or address. You do not have to give a reason for your request.

Right to a Paper Copy of this Notice of Privacy Practices: You have a right to a paper copy of this signed notice.

Other uses and disclosure of PHI and any disclosure of Case Notes will be made only with your written authorization. After such authorization is given, you may revoke that authorization at any time from future use. This notice may be amended as needed to comply with federal, state, and professional requirements.

Notice of Privacy Practices Receipt Form
By signing below, I attest that I have read and received a copy of the Notice of Privacy Practices from the staff of Pavo Behavioral Therapy.

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Pavo Behavioral Therapy uses a shared treatment space where other clients or clients’ family members/caregivers may be present. While our employees are expected to follow strict confidentiality rules, we also ask that our clients and their families respect the confidentiality of the other clients at our clinic.

We ask that clients and clients’ family members/caregivers agree not to disclose any information in relation to any other clients at Pavo Behavioral Therapy. This includes:

• Not discussing any information pertaining to any client or client family members with anyone.
• Not discussing any information pertaining to any client or client family members in any place where it can be overheard by others.
• Not releasing any information, in writing or orally, regarding a client or client family members.

I understand that violation of this confidentiality policy could potentially result in my/my child’s termination from Pavo Behavioral Therapy. Further, breaching of confidentiality may subject me to civil or criminal liability.

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Pavo Behavioral Therapy aims to help as many families as possible, and we seek out various funding opportunities, including insurance, Medicaid, and self-funding.

Insurance: Pavo Behavioral Therapy will ensure that all pre-authorization, assessment and progress reports are completed and submitted before the due dates to continue ongoing therapy. However, if any claim comes back as uninsurable, you will be billed for the full amount of services after 60 days. As such, it will be your responsibility to contact your insurance company for reimbursement. You are responsible for any charges, or portions of charges that your insurance company does not cover. Pavo Behavioral Therapy will release all necessary paperwork to the parent or caregiver as requested.

Self-Funded: Pavo Behavioral Therapy and the parent/caregiver will determine the number of ABA therapy hours per week and supervision per month (one hour of supervision for every 10 hours of ABA therapy provided).

The parent/caregiver will receive a monthly bill, with payment due within 30 days of the invoice date. If payment is not received within 30 days of the invoice date, then Pavo Behavioral Therapy has the right to place the account on hold and stop services until payment has been received in full.

The two options for Self-Funded clients are:

Pre-Pay:
If you pre-pay for monthly ABA services, you will receive a timely payment rate, which is based on the agreed amount. The following criteria must be met to qualify for the pre-pay plan:

1. A Behavior Technician (trained and supervised closely by the BCBA) must conduct at least 50% of all scheduled therapy sessions.
2. Payment must be received on or before the due date as written on the invoice (within 30 days from the date of the invoice).
3. All documents must be signed and returned within 72 hours of receipt. If additional time is required, please discuss this with a Pavo Behavioral Therapy team member.

The pre-paid rate will increase to the standard hourly rate if there is non-compliance of any of the three terms above. In the case of non-compliance, you will receive an email within 48 hours and be notified of the rate increase. After one incident of non-compliance, the parent or caregiver can return to pre-pay rates following compliance of the three terms of standard rates. However, if payment is not received within 30 days of the due date printed on the invoice, Pavo Behavioral Therapy reserves the right to place services on hold until payment is received in full.

Standard Rate:
Services will be billed at the standard hourly rate. Payment must be received no later than 30 days of the invoice date (due date will be posted on the invoice). If payment is not received by the due date as stated on invoice, there will be a late charge of $60.00 applied to your account, and Pavo Behavioral Therapy reserves the right to place services on hold until payment is received in full.

Standard Rates:
ABA Tech: $75/hour
BCBA: $100/hour

*We maintain an up-to-date fee schedule on your online account. Parents are given at least 60 days’ notice of any fee changes.

The terms of this agreement will continue until either party provides written notice of termination request. Termination will take place 30 days from the date of the request, and termination reports (a minimum of 4 hours billed at the BCBA rate) will be provided at the time of termination. If a notice of termination is not provided in writing, one week of service will be billed to the parents.

Invoices:

Pavo Behavioral Therapy will invoice families monthly. You will receive an itemized invoice, with a breakdown of the date of service, time of service, and service type. You will receive an electronic invoice on the last day of each month. Paper copies are available upon request; fora paper copy, please send an email to kellykohler@pavocare.com. The parents/guardians of the child receiving services remain completely responsible for the full payment of all services, including late payment fees. We accept payment via online banking, check or money order.

Fees:

• There is a $40 returned check fee for all checks returned by the bank.
• Appointments must be canceled at least 24 hours in advance or you will be subject to a $60 missed appointment fee.
• There is a late payment charge of $60 as described above.
• Any requests for printed records will take up to 30 days and cost a flat fee of $20.

ABA Therapy Service Agreement
During the term of this agreement, Pavo Behavioral Therapy will provide ABA Therapy services, and the parents/guardians will compensate Pavo Behavioral Therapy a payment for the services as described below in the terms and conditions specified. I understand all the fees and conditions as stated above.

IF IT BECOMES NECESSARY FOR THIRD PARTY COLLECTION, I AGREE TO PAY FOR ALL COSTS AND EXPENSES INCLUDING REASONABLE ATTORNEY FEES.

Services
During the terms of this agreement Pavo Behavioral Therapy shall provide the following services:

• Behavioral treatment may include but are not limited to: direct one-on-one instruction, skills assessments, modifications of programs (data review), Functional Behavior Assessments, and parent training.
• Other professional services can be requested but are not included in this service agreement may include, but are not limited to:

o Program development
o Attendance to meetings or consultations with other professionals
o Preparation of records or treatment summaries
o Time required to perform any other service which you may request

I authorize Pavo Behavioral Therapy to release information requested by my insurance company or other funding agency (e.g., CMH) to complete my claim and request payment for my child’s services.

Authorization to Pay Claims
I authorize payment from the insurance company or other funding agency to be directly sent to Pavo Behavioral Therapy. This allows Pavo to file claims on my behalf.

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1. There is imminent risk of serious harm to the individual or staff.
2. There are no other ways to de-escalate without physical harm.
3. The risk of not intervening is greater than the risk of intervening.

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All behavioral staff members for at Pavo Behavioral Therapy are mandated reporters as deemed so by Michigan’s rules, regulations, and laws. This is true of all social workers, teachers, etc., and should not restrict the work to be completed. This is a state law designed to protect children from injury and should not be viewed as means to harm parents and caretakers.

This form shall serve as a reminder to the family of this fact and shall also provide insight into what this disclosure means. This disclosure shall serve as part of the client education regarding the program, and the client information packet.

Being deemed a mandated reporter, staff are required by law to report any and all allegations, reports, and suspicions of child abuse, neglect, and maltreatment to the appropriate identified governing body. Child Protective Services is the governing body identified in the state of Michigan regarding cases of child abuse, neglect, and maltreatment; and staff shall therefore report the incidents mentioned above to the National Hotline for Child Protective Services.

Any report to Child Protective Services, where deemed necessary by them, shall constitute a separate case from the one managed by Pavo Behavioral Therapy LLC. For this reason, it should be noted that the behavior staff shall only participate in CPS cases as required and requested by Child Protective Services. Pavo Behavioral Therapy shall play no part in decisions made by Child Protective Services and should be viewed as a separate organization from Child Protective Services.

The client shall sign a Mandated Reporter Disclosure Receipt Form that shall be kept in the client’s file as evidence that the information mentioned above has been provided to the client and family.

Mandated Reporter Disclosure Receipt

I have read and received a copy of the Mandated Reporter Disclosure policy from Pavo Behavioral Therapy LLC.

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Authorized individuals may be asked for identification. Clients will not be released to anyone who fails to provide acceptable identification upon request.

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• I understand that this authorization is voluntary, and I have the right to revoke this authorization, in writing, at any time.
• I understand that a revocation will not apply to any information that was already shared as a result of this authorization.
• I understand that this authorization will automatically expire 30 days after the termination of services.

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