Appendices

Copayments, Coinsurance, & Cost Share

Uniform policy for collecting and documenting client cost-sharing amounts.

Care Coordination Policy

Communication and information sharing across providers with parental authorization.

Client Intake Questionnaire

Initial intake sheet completed at first appointment.

1 attached form

Client Folder Checklist

Standards for maintaining client records and required documentation.

1 attached form

ABA Clinical Documentation Protocol

Documentation requirements for CPT codes 97151, 97155, and 97156, including required note elements, payer audit risks, and a pre-finalization checklist.

Extended Service Hours Authorization

Medical necessity and clinical justification standards for services delivered before 7:00 AM, after 8:00 PM, on weekends, or on holidays, with the supervising-analyst rubric and attestation required for approval.

1 attached form

RBT Progress Notes Protocol

Standards and structure for RBT session documentation.

RBT Supervision Protocol

Supervision standards, frequency, and documentation for Registered Behavior Technicians.

Consent for Treatment

Parent and guardian consent for behavior analysis services.

2 attached forms

Clients Rights and Responsibilities

Sample client form covering rights, ethical obligations, and responsibilities.

1 attached form

Bill of Rights

Client bill of rights as a standalone acknowledgment.

1 attached form

Payment Contract for Services

Financial obligations and payment terms between client and clinic.

1 attached form

Employee Acknowledgement

Policy acknowledgements and attestations signed by employees at hire.

1 attached form

Contractor Acknowledgement

Policy acknowledgements and attestations signed by contractors at engagement, including contractor-specific clauses (software fee, contract termination notice, tools and materials, payment contingency).

1 attached form

Direct Deposit Authorization Form

Authorization for payroll direct deposit.

1 attached form

Employee Handbook

Embedded reference to the standalone Employee Handbook workspace.

Employee Contract

Standard employment contract for W-2 staff.

1 attached form

Independent Contractor Service Agreement

Service agreement for 1099 contractors.

1 attached form

Background Screening and Exclusion Monitoring

AHCA Level II screening, OIG/LEIE and SAM.gov exclusion monitoring, multi-source verification, frequency, duty to report, and ongoing monitoring.

Clinical Director Job Description

BCBA Clinical Director responsibilities, qualifications, and reporting structure.

BCBA Job Description

BCBA position summary, minimum qualifications, and responsibilities across assessment, treatment planning, supervision, caregiver training, documentation, compliance, coordination of care, safety, confidentiality, ethics, work environment, and performance expectations.

Job Description: RBT

RBT direct service responsibilities, training, and supervision requirements.

AI Usage Policy

Rules governing the use of AI tools in clinical and administrative work.

Initial Job Application

Pre-employment application form for staff and contractors.

1 attached form

Required Documents Checklist

Required employment documentation and verification procedures.

1 attached form

Physical Examination Form

Pre-employment physical examination form.

1 attached form

Job Description: Documentation QA Specialist

QA Specialist documentation review, audit, and compliance responsibilities.

Job Description: Finance / Billing Liaison

Finance and billing liaison responsibilities for claims, payments, and reconciliation.

Billing and Claims Submission

End-to-end billing workflow from documentation to claim submission and reconciliation.

Job Description: Director of Human Resources

HR Director responsibilities for hiring, compliance, and personnel records.

Job Description: Intake Specialist

Initial contact with guardians, completion of the Client Intake Questionnaire, and insurance eligibility verification for prospective clients.

Job Description: President / Administrator / CEO

Executive responsibilities for governance, strategy, and organizational compliance.

Incident Reporting

Documentation and notification protocols for clinical and safety incidents.

1 attached form

Emergency / Disaster Preparedness and Continuity of Operations Plan

Scope of services during emergencies, mitigation, hurricane preparedness, service suspension criteria, behavioral support, HIPAA safeguards, documentation, recovery, staff responsibilities, and chain of command.

Discharge and Transition of Services Policy

Rationale, scope, general guidelines, criteria (clinical improvement, medical necessity, transfer, request, funding, attendance, safety), planning process, coordination of care, documentation, and recipient rights.

Discharge Notification Form

Client and caregiver notification when services are discharged.

1 attached form

Clinical Progress Discharge Summary

Clinical companion to the Discharge Notification Form: progress areas, maladaptive behavior status from intake to discharge, skill acquisition status, caregiver participation, recommendations, and the overall discharge clinical impression. Used together with or in place of the notification letter, depending on the clinic's documentation needs.

1 attached form

Organizational Chart

Reporting structure for clinical and administrative staff.

Drug-Free Workplace

Policy on substance use, testing, and workplace safety.

Agency-Provided Transportation Services

Standards for safe and authorized client transportation.

Complaint Form

Submission form for client and caregiver complaints.

1 attached form

Grievance Log Form

Log used to track grievance receipt, investigation, and disposition.

1 attached form