Montana Developmental Assessment Clinic

Policy Agreement and Conditions of Service Agreement 2024-2025

Notice of Privacy Policies

Montana Developmental Assessment Clinic

Patient Name: ____________________________________

In signing this form, you consent to the use and disclosure of your child’s protected health information by

the Montana Developmental Assessment Clinic, our staff and business associates, strictly for the purpose

of treatment, payment, research and health care operations.

We are collaborating with the University of Mary in research using data from this clinic. The student and

faculty researchers will follow our privacy standards. All personal health information will remain protected:

the research data will be coded and deidentified to ensure confidentiality compliance.

We may be videotaping the Autism Diagnostic Observation Scale and formal psychological assessments

as these may need to be reviewed by those scoring the test. The tape will only be used for the

assessment and then destroyed.

You have the right to request an electronic or paper copy of your child’s medical record, an amendment to

your child’s medical record, confidential communication from us, and a list of those with whom we have

shared information. You may also request that we restrict how we use and disclose you and your child’s

protected health information. You can ask for a restriction to that disclosure. We have the right, however,

to deny your request in certain circumstances.

The MT Developmental Assessment Clinic will not use or share you or your child’s information other than

for the purposes of treatment, payment and health care operations. We will maintain the privacy and

security of your child’s protected health information. We will let you know promptly if a breach occurs that

may have compromised the privacy or security of your child’s information.

By signing this form, I grant my consent for Montana Developmental Assessment Clinic to use and

disclose my child’s protected health information for the purposes of treatment, payment, research or

health care operations.

Conditions of Service

Montana Developmental Assessment Clinic

You may receive three bills for the Montana Developmental Assessment Clinic.

-- Montana Developmental Assessment Clinic which includes Dr. Nicholson, the

ADOS 2 (Autism Observation Scale) and other Developmental testing and

questionnaires.

-- Speech Therapist (SLP): Nancy Rice, Anna Potuzak or Kendra Grass, SLPs

-- Occupational Therapist (OT): Yellowstone Therapy Center for Paula Kitzenberg,

Little Legends, Wild Roots, LEAF or____________________________________

-- Psychological Evaluation: done by Keystone Counseling (4 and older)

The form below applies to the billing of services from all of these entities

1. When you present a current insurance card, the Assessment Clinic Providers–

including all of the above, will file your insurance claim. It is your responsibility to

contact your insurance company with questions concerning the status of outstanding

claims.

2. If your insurance requires a copayment: These are collected with the overall

insurance payment.

3. Assignment of Benefits and Promise of Payment: With my signature, I authorize

my insurance company or health plan to pay medical benefits on my behalf directly

to the MT Developmental Assessment Clinic providers. I understand and agree that

I remain financially responsible for the payment of all medical services provided by

the MT Developmental Assessment Clinic. If the providers at the Assessment Clinic

are not participating providers with my health plan, I understand and agree that the

MT Developmental Assessment Clinic (Assessment Clinic, OT, SLP and/or

Psychologist) may choose not to bill my health plan and that I will be billed for all

services. I authorize the providers of the MT Developmental Assessment Clinic

(including OT and SLP) to use or disclose my healthcare information to assist in

obtaining reimbursement for services rendered.

4. Discount Program: If your household has a gross income less than 200% of the

Federal Poverty Level or you are experiencing significant financial hardship, you

may be eligible for discount. You will need to submit the request in writing and

supply relevant tax and other relevant financial documents.

5. The providers of the Montana Developmental Assessment Clinic appreciate

payment in full within thirty (30) days from invoice date. However, if it is not

possible to make payment in full, it is your responsibility to set up a payment plan by

notifying the providers.

6. Appointment of the Montana Developmental Assessment Clinic (Doctor, OT

and SLP) as Authorized Representatives: I understand the Autism

Developmental Assessment Clinic may assist in pursuing a claim or appeal of a

denied claim. With my signature, I authorize and appoint the Providers of the MT

Developmental Assessment Clinic to act on my behalf and/or on behalf of my

covered child/dependent (under 18 years of age) as my authorized representative

with any insurance carrier with whom valid insurance coverage exists for medical

services. I further direct that any payment made by any insurance carrier as a

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result of a successful appeal is to be paid directly to the Providers of the Montana

Developmental Assessment Clinic (Doctor, SLP, OT and/or Psychologist). This

authorization and appointment will remain valid until such time as I revoke this

authorization and appointment in writing to the MT Developmental Assessment

Clinic and my insurance carrier(s)

I have read and understand the above policy. I understand I can request a copy of this

agreement for my records as the Responsible Party on the account.

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