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Telemedicine Healthcare Options Available

NOW OFFERING WEIGHT LOSS TREATMENT!!!
SEMAGLUTIDE INJECTION ($199 For First Month)!!!

Clifton Location: (513) 616-8774, Fairfield Location: (513) 860-9888

Clifton Location: (513) 616-8774
Fairfield Location: (513) 860-9888

New Patient Registration Form New

To be started by the patient and completed with help from a Counselor or Nurse Identifying & Demographic Information

Date(Required)

Name(Required)

First Name Middle Name Last Name

DOB(Required)

SSN(Required)

Address(Required)

Address City State Zip Code Country

Gender

Male

Female

Pronouns

Race

Home Phone(Required)

Cell Phone(Required)

Consent the call?

Yes

No

Consent the text?

Yes

No

Email(Required)

Referring Agency or Person

Marital Status(Required)

Student

Yes

No

Medicaid

Yes

No

Hidden

Marital Status(Required)

Medicaid Provider Number(Required)

Commercial Insurance Name Address(Required)

Member ID(Required)

Group Number(Required)

Policy Holder Name(Required)

Are you a United States Military Veteran?(Required)

Yes

No

Were you in Military Service?(Required)

Yes

No

Do You Currently Have Stable Housing?(Required)

Yes

No

If Homeless Can You Be Reached?(Required)

Yes

No

If No, Are You Interested in Stable Housing Resources?(Required)

Yes

No

Tel.(Required)

Emergency Contact Information

Emergency Contact Name

Emergency Contact Full Address

Emergency Contact Phone

Substance Abuse/Addiction History

Do You Use Recreational Drugs?

Yes

No

If Yes, What Drugs Do You Use?

If Yes, How Often Do You Use?

What is Your Main Problem With Drugs?

What is/are Your Drug(S) of Choice?

How Long Have You Used?

When Was Your Last Use?

What Was the Amount That You Used (Dollar Amount or Another Quantifying Amount? (Grams, Miligrams,etc.)?

Have You Ever Overdosed?

Yes

No

If Yes When?

Were You Administered NARCAN by Anyone?

Yes

No

If Yes How Many Times?

At What Age Did You Start Using Drugs?

How Long Have you been using Opioids?

Do you

Inject

Snort/Inhale

Skin Pop (in muscle)

Oral route opioid drugs?

How did you start using drugs?

Have you been enrolled in alcohol or other drug treatment in the last 90 days?

Yes

No

If yes, where?

If yes, what period?

Did you complete the program?

Yes

No

If yes when did you complete the program?

If no, please explain why you did not complete the program

Did you use other drugs?

Yes

No

List other drugs:

Mental Health History

Are You Currently Under a Psychiatrist’s Care?(Required)

Yes

No

If Yes, When Was Your Last Visit?(Required)

If Yes, What is Your Psychiatrist’s Contact Information?(Required)

Are You Currently Being Prescribed Medication by a Psychiatrist?(Required)

Yes

No

If Yes, please list your prescribed medications(Required)

Abuse History

Have Your Ever Been Abused?(Required)

Yes

No

If Yes, Check All That Apply(Required)

Physically

Emotionally

Verbally

Sexually

Primary Care History

Do You Currently Have a Primary Care Physician?(Required)

Yes

No

If Yes, When Was Your Last Visit?(Required)

If Yes What is Your Primary Care Physician’s Name or Practice Name?(Required)

If Yes, What is Your Primary Care Physician’s Contact Information?(Required)

Are You Currently Being Prescribed Medications by Your Primary Care Physician?(Required)

Yes

No

If Yes, List Your Prescribed Medications(Required)

If Yes, for Which Illness and or Issues Are You Currently Seeing Your Physician?(Required)

If No, Are You Interested in Obtaining a Primary Care Provider?(Required)

Yes

No

Current or Past Medical Conditions

(Check all that apply and write F if the illness has a family history)

Asthma/ Respiratory

Cardiovascular (Heart Attack, high Cholesterol, angina)

Thyroid

GI Disease

Hypertension

Epilepsy/Seizure Disorder

Diabetes

Liver

Pancreatic problems

Abnormal Pap Smear

Nutritional issues

HEP C

HEP B

HIV

Other Allergy

Other

Other

Asthma/ Respiratory

Cardiovascular(Heart Attack, high Cholesterol, angina)

Thyroid

GI Disease

Hypertension

Epilepsy/Seizure Disorder

Diabetes

Liver

Pancreatic Problems

Abnormal Pap Smear

Nutritional Issues(Required)

HEP C

HEP B

HIV

Are You Pregnant?(Required)

Yes

No

Not Sure

List Known Allergies(Required)

Tobacco Use History

Do You Smoke?(Required)

Yes

No

If Yes, How Much Per Day?(Required)

If Yes, How Long Have You Smoked?(Required)

Legal Occurrences

Are You Currently Experiencing Any Legal Issues?(Required)

Yes

No

If Yes Please Explain(Required)

Do You Have a Probation/parole Officer(Required)

Yes

No

If Yes, What is Your Probation/parole Officer’s Name?(Required)

If Yes, Which County(Ies) Does Your Probation/parole Officer Represent?(Required)

If Yes, What is Your Probation /parle Officer’s Contact Information?(Required)

Are You Involved With Child Protective Services?(Required)

Yes

No

If Yes, What is Your Cps Case Worker’s Name?(Required)

If Yes, Which County(Ies) Does Your CPS Case Worker Represent?(Required)

If Yes, What is Your CPS Case Worker’s Contact Information?(Required)

Patient Signature(Required)

Date(Required)

Consent for Treatment

Name(Required)

DOB

MM slash DD slash YYYY

Patient ID

Admit Date

MM slash DD slash YYYY

I

knowing that I am experiencing symptoms requiring The Health Experiences (THE) services voluntarily consent to such medical care encompassing routing diagnostic procedures, alcohol and or drug assessment mental health treatment and medical treatment by T.H.E medical staff.

RECEIVING MEDICAL SERVICES OTHER THAN OFFERED AT T.H.E:

I understand that should major medical services become necessary, T.H.E will not be held medically legally financially responsible for providing such services. Should such services deemed medically appropriate by the consulting physician, The Health Experiences will make every reasonable effort to refer me to the proper clinic, hospital or doctor, Basic medical services will be provided by The Health Experiences Medical staff as determined by the consulting Physician.

RELEASE OF INFORMATION TO BE USED FOR PAYMENT, TREATMENT, OR FACILITY OPERATIONS:

I authorize the release of medical record information including, but not limited to drug and/or alcohol related conditions, psychiatric conditions, and or HIV/AIDS related information to the responsible insurance carrier, third party payers, or their responsible representatives, review organizations or their representatives, the physician or agency staff responsible for method of care and/or any health care facility to which I am transferred from T.H.E All information released will be based on the minimum standard as defined by HIPPA.

FINANCIAL RESPONSIBILITY:

I hereby authorize payment directly to The Health Experiences and/or the attending physician or their designees or all insurance benefits payable to me. I acknowledge that I am responsible for the payment for all services rendered by The Health Experiences on my behalf.

PERSONAL BELONGINGS SEARCH:

I understand that all personal belongings are subject to search by staff members in my presence. The purpose of this is to identify articles that are not permitted in the building. I understand that legal items found during the course of the searches may be stored and returned to me at the time of my discharge.

Patient Signature(Required)

Date(Required)

Witness Signature(Required)

Date(Required)

If patient is unable to sign consent, please state why

Relative/Guardian(Required)

Date(Required)

Witness Signature(Required)

Date(Required)

AGAINST MEDICAL ADVICE DOCUMENT

This is to verify that I am leaving The Health Experiences against the advice of the attending physician and the agency administration. I acknowledge that I have been informed of the risks involved with my decision and hereby release the physician and The Health Experiences from all responsibility and any ill effects that may result from this action.

Patient Signature(Required)

Date(Required)

If patient is not available why

Telemedicine/Email/Text Consent

Patient Name

DOB

MM slash DD slash YYYY

Client ID

1. I understand that my health care provider wishes me to engage in a telemedicine consultation.

2. My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit since I will not be in the same room as my health care provider.

3. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the video conferencing connections are not adequate for the situation.

4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider and consulting health care provider to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

5. I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.

6. In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner, and that the specialist’s responsibility will conclude upon the termination of the video conference connection.

7. I understand that billing will occur from both my practitioner and as a facility fee from the site from which I am presented.

8. I have had a direct conversation with my doctor, during which I had the opportunity to ask questions regarding this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

9.We offer appointments confirmation messages and reminders by text message and/or email. If you wish to receive these messages and/or emails, we require your consent.

10. If you wish to receive these text messages and/or emails, please read the disclaimer below then complete and sign this form.

Consent(Required)

I consent to The Health Experiences and its staff contacting me via text message and/or email for health promotions and appointment reminders. I also understand that standard text messaging may apply. I acknowledge that the responsibility of attending appointments and cancelling them still rests with me. I can opt out of the text and/ or email function at any time by submitting your wish to discontinue text or email services in writing. I agree to advise the practice of my mobile number and/or email changes if no longer in my possession.(Required)

By signing this form, I certify:(Required)

That I have read or had this form read and/or had this form explained to me

That I fully understand its contents including the risks and benefits of the procedure(s).

That I have been given many opportunities to ask questions and that any questions have been answered to my satisfaction.

Patient’s/parent/guardian signature(Required)

Date(Required)

Time

Hours

:

Minutes

AM/PM

Witness Signature(Required)

Date(Required)

Time

Hours

:

Minutes

AM/PM

THE HEALTH EXPERIENCES

Patient Name:

Date

MM slash DD slash YYYY

Patient ID:

Patient Treatment Contract

As a participant in Buprenorphine treatment for opioid misuse and dependence, I freely and voluntarily agree to accept this treatment contract as follows:

I agree to keep and be on time for all my scheduled appointments.
I agree to adhere to the payment policy outlined by this office.
I agree to conduct myself in a courteous manner in the doctor’s office.
I agree that excessive profanity will not be tolerated.
I agree to comply with the no tobacco products policy.
I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.
I agree not to deal, steal, or conduct any illegal or disruptive activities in the doctor’s office.
I agree not to bring into the facility any weapons, drugs, or drug paraphernalia.
I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees or the pharmacy where my Buprenorphine is filled, that the behavior will be reported to my doctor’s office and could result in my treatment being terminated without any recourse for appeal.
I agree that my medication/prescription can only be given to me on my regular office visits. A missed visit may result in my not being able to get my medication/prescription until the next scheduled visit.
I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of why it was lost.
I agree not to obtain medications from any doctors, pharmacies, or other sources without first telling my treating physician.
I understand that mixing Buprenorphine with other medications, especially benzodiazepines (for example, Valium, Klonopin, or Xanax), can be dangerous. I also recognize that several deaths have occurred among persons mixing Buprenorphine and Benzodiazepines (especially if taken outside the care of a physician, using routes of administration other than sublingual or in higher than recommended therapeutic doses).
I agree to take my medication as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor.
I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as discussed and agreed upon with my doctor and specified in my treatment plan.
I agree to abstain from alcohol, opioids, marijuana, cocaine, and other addictive substances (excluding nicotine).
I agree to provide urine drug screens and my medication for count when randomly requested to do so.
I understand that there is no fixed time for being on Buprenorphine and that the goal of treatment is to stop using all illicit drugs and become successful in all aspects of my life.
I understand that I may experience opioid withdrawal symptoms when I go off Buprenorphine.
I have been educated about the other FDA-approved medications for opioid dependence treatment, Methadone and Naltrexone.
If female, I have been educated about the increased chance of pregnancy when stopping illicit opioid use and starting Buprenorphine.
I agree I have been informed of orientation and where I can receive a client handbook.
I understand that any violations of the above may be grounds for termination of treatment.

Patient Signature(Required)

Date(Required)

Time

Hours

:

Minutes

AM/PM

Witness(Required)

Date(Required)

Time

Hours

:

Minutes

AM/PM

Income Verification and Fee Agreement

Date

MM slash DD slash YYYY

Name:

Patient ID:

Address

Street Address City State / Province / Region

SSN

DOB

MM slash DD slash YYYY

Marital Status

Number in family including yourself

Spouse Name

INCOME:

Employer Name

Monthly Income:

Spouse’s Employer

Monthly Income:

OTHER INCOME:

Social Security

SSI

TANF

DA

Pension

Total Monthly Income:

Medicaid will cover the fees for routine services I receive from The Health Experiences

Alcohol & Drug/ Mental Health Assessment MD/NP: $300.00 per hour
Intensive Outpatient: $136.90
Mental Health Assessment Counselor: $96.24
Med/Som visit $180.00 MD/NP per visit
Crisis Intervention: $164.55
Alcohol/Drug Assessment Counselor: $96.24
Individual Counseling: $87.28
Case Management: $22.03 per 15 min
Laboratory Analysis: $16.33
Non-Intensive Group Counseling: $41.19

Credit Card Payments are subject to 3% processing fee

I FULLY UNDERSTAND AND AGREE TO THE FOLLOWING:

In signing this document, I authorize the release of sufficient information to determine my need for eligibility for public funded services and to enroll me in the Medicated Assisted Treatment Program.
I am liable for the full cost of the services provided which are not covered by third party payors.
Third party payors (Medicaid, Medicare, Private Insurance) will be billed for any covered services to the extent I am eligible.
I also understand that should I lose my health benefits I am solely responsible for the service fees.

I attest that the above information is accurate and true to the best of my knowledge.

*No written verification of participation in services will be made to the referral source (probation lawyers, court system) until the fees are paid in full.

Client Signature(Required)

Date

MM slash DD slash YYYY

Parent/Guardian Signature(Required)

Date

MM slash DD slash YYYY

Staff Signature(Required)

Date

MM slash DD slash YYYY

199 William Howard Taft Rd. Cincinnati Ohio 45219

HIPAA Information and Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protection to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

Patient information will be kept confidential except as it is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and recent technology that you might find valuable or informative.
The practice utilizes several vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
We agree to provide patients with access to their records in accordance with state and federal laws.
We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient.
You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I

Date

MM slash DD slash YYYY

do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

Email

This field is for validation purposes and should be left unchanged.

Behavioral health/MAT New Patient Registration Form

REGISTRATION FORM

REGISTRATION FORM (PLEASE PRINT)

Today’s Date(Required)

PCP(Required)

Patient Information

(Required)

First Name Middle Initial Patient Last Name

Marital Status(Required)

Hidden

Marital Status(Required)

Former Name(Required)

Date Of Birth(Required)

Sex at Birth(Required)

Address(Required)

Street Address City State Zip Code

Home Phone(Required)

Cell Phone(Required)

Occupation(Required)

Referred to Clinic by(Required)

Hidden

Language

Gender Identity

Language

Gender Identity Other

Race

Pronouns

Race Other

Consent the call

Consent the text

INSURANCE INFORMATION

(please give insurance card to receptionist)

Person Responsible for Bill(Required)

Date of Birth(Required)

Address If Different(Required)

Phone Number(Required)

Is the Responsible Party a Patient(Required)

Yes

No

Responsible Party Occupation(Required)

Responsible Party Occupation(Required)

Responsible Party Employer Address(Required)

Responsible Party Employer Phone Number(Required)

Is This Patient Covered by Insurance?(Required)

Yes

No

Please Indicate Primary Insurance

Name of Insurance(Required)

Subscriber ID(Required)

Group #(Required)

Subscribers Name(Required)

Subscriber DOB(Required)

Patient’s Relationship to Subscriber(Required)

Self

Spouse

Child

Other

IN CASE OF EMERGENCY

Name

Relationship to Patient

Home/Cell Phone

Work Phone

This above information is true to the best of my knowledge, I authorize my insurance benefits be paid directly to the physician/Clinic. I understand that I am financially responsible for any balance, I also authorize The Health Experiences or insurance company to release any information required to process my claims

Patient/Guardian Signature(Required)

Date(Required)

MEDICATION LIST

Name(Required)

DOB(Required)

MEDICATION(Required)

DOSE(Required)

HOW OFTEN(Required)

PRESCRIBER(Required)

Allergies and Reactions(Required)

Pharmacy Name(Required)

Pharmacy Phone(Required)

Pharmacy Address(Required)

Signature(Required)

Date(Required)

THIS FORM MUST BE COMPLETED IN IT’S ENTIRETY BY THE PATIENT OR PATIENT’S AUTHORIZED REPRESENTATIVE THE HEALTH EXPERIENCES PRIMARY CARE Authorization For Disclosure Of Protected Health Information

Patient Name(Required)

Maiden Name(Required)

Phone Number(Required)

Date Of Birth(Required)

Address(Required)

1. Provider Making Disclosure I authorize:(Required)

(referred to as “Health Care Provider”) to release my/the patient’s individually identifiable health information as described below.

2. Recipient of Health Information: I authorize The Health Care Provider to release the information described in this authorization:

3. Information To Be Released: Describe information you want to be disclosed pursuant to the Authorization:

A. Medical Records: (check “All Medical Records Or Other)(Required)

All Medical Records

Other I only want the following parts of my medical record to be disclosed:

Other(Required)

B. Billing Records: (Check if you want billing records released)(Required)

Billing Records

C. Dates Of Treatment: (Check “All dates of Treatment” or Specific dates of treatment”)(Required)

All dates of Treatment

Specific dates of treatment: I only want records for the following dates of treatment disclosed:

Other(Required)

Further I authorize the release of any information contained in the above records concerning treatment of drug or alcohol abuse, drug related conditions, alcoholism and/or Acquired Immune Deficiency Syndrome (AIDS) and/or testing for antibodies to the aids VIRUS (HIV) and/or psychiatric/psychological conditions and/or psychiatric/mental health treatment

4. Your refusal to sign this authorization: The Health Care Provider may not condition treatment on whether or not you sign this authorization. If you refuse to sign this Authorization, the health care provider will not withhold treatment from you and will not release the information to the person or organization specified above.
5. Purpose for the use of disclosure: The purpose for the disclosure is at the patient’s request.
6. Oral Communication I understand that this authorization allows the Health Care Provider and it’s employees to discuss my individually identifiable health information described herein with the recipient of the information
7. Re-Disclosure: I understand that the information used and/or discussed pursuant to this Authorization may be re-discussed by the recipient of the information and may no longer be protected by Federal law. However, If the information disclosed pursuant to the Authorization include alcohol or drug treatment records, the person(s) receiving such disclosure is hereby notified that this information has been disclosed from confidential records protected from disclosure by Ohio law. Ohio law prohibits such person(s) from making any further disclosure of this information without the specific written and informed release of the patient to whom it pertains, or as otherwise permitted by Ohio law. A general authorization for the release of medical or other information is not sufficient for the purpose of the release of HIV test results or diagnosis.
8. Revocation: I understand that I may revoke this authorization at any time by notifying the Health Care Provider in writing by sending a letter to the attention of the Manager of the medical records department at the Health Care Providers mailing address. I understand that if I revoke this authorization it will not affect any actions that the health Care Provider took before it received my revocation letter.

9. Expiration: This Authorization will expire one year after the date below, or sooner by choice, in which case this Authorization will expire on

un(Required)

(if applicable, insert date)

Note You may not indicate there is no expiration. However, if the records to be used or disclosed pursuant to this Authorization concern psychiatric, psychological and/or mental health treatment, this Authorization will expire 90 days after the date below, or sooner by choice, in which case this authorization will expire on

un(Required)

(if applicable, insert date)
Note: You may not indicate there is no expiration date.

Signature of Patient or Patient’s Representative(Required)

Date(Required)

Printed Name of Patient and/or Patient’s Representative(Required)

Date(Required)

If “legal guardian” or “Other”, legal documentation of Representative’s authority must accompany this authorization

PLEASE NOTE THERE MAY BE A CHARGE TO COPY RECORDS.

THE HEALTH CARE PROVDIER MAY USE A COPY SERVICE AND IT MAY BILL YOU DIRECTLY

THE HEALTH EXPERIENCES

Patient Consent for Use and Disclosure of Protected Health Information

I hereby give my consent for THE HEALTH EXPERIENCES TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI) about me to carry out treatment. payment and health care operations(TPO). A. (The Notice of Privacy) Practices provided by THE HEALTH EXPERIENCES describes such uses and disclosures more completely.
I have the right to review the Notice of Privacy Practices prior to signing this consent. THE HEALTH EXPERIENCES reserves the right to revise it’s Notice of Privacy Practices at any time. A revised Notice of Privacy may be obtained by forwarding a written request to 199 William Howard Taft Road Cincinnati, Ohio 45219.
With this consent, THE HEALTHE EXPERIENCES may call my home or other alternative location and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminder, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, THE HEALTH EXPERIENCES may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”
With this consent, THE HEALTH EXPERIENCES may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statement. I have the right to request that THE HEALTH EXPERIENCES restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow THE HEALTH EXPERIENCES to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, THE HEALTH EXPERIENCES may decline to provide treatment tome.

Signature of Patient or Legal Guardian(Required)

Date(Required)

Print Patient’s Name and/or Printed Name of Guardian(Required)

TELE MEDICINE CONSENT FORM

Patient Name(Required)

DOB(Required)

Client ID(Required)

I understand that my health care provider wishes me to engage in a telemedicine consultation.
My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit since I will not be in the same room as my health care provider.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the video conferencing connections are not adequate for the situation.
I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my health care provider and consulting health care provider to operate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.
In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the video conference connection.
I understand that billing will occur from both my practitioner and as a facility fee from the site from which I am presented.
I have had a direct conversation with my doctor, during which I had the opportunity to ask questions regarding this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

By Signing This Form, I Certify(Required)

That I have read or had this form read and/or had this form explained to me

That I fully understand its contents including the risks and benefits of the procedure(s).

That I have been given many opportunities to ask questions and that any questions have been answered to my satisfaction.

Patient’s/Parent/Guardian Signature(Required)

Date(Required)

Time(Required)

Hours

:

Minutes

AM/PM

Witness Signature(Required)

Date(Required)

Time(Required)

Hours

:

Minutes

AM/PM

Comments

This field is for validation purposes and should be left unchanged.

Primary Care Registration Form

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Home
About
- Our Team
- Mission & Vision
Services
Gets Started
Privacy
- Privacy Notice
- Client Rights
Contact
Career

View Our Services

Our Team

Staff

MSH_062A2229 (1)

Curtis Cooper

MSH_062A2221

Jasmine Cooper

MSH_062A2236

Scott Pate

MSH_062A2192

Brandi Martinez

MSH_062A2223

Sharlene Lillie

MSH_062A2238

Michael McClure

Locations

Clifton Location:
199 William Howard Taft Road
Cincinnati, Ohio 45219
Fairfield Location:
640 Nilles Road
Fairfield, Ohio 45014

Contact Info

Clifton Location : (513) 616-8774
Fairfield Location : (513) 860-9888
rlim@thehealthexperiences.com

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