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.

1. Engagement in Telemedicine Consultation

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

2. Explanation of Telemedicine Technology

My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation. It 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. Potential Risks

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. Healthcare Information and Confidentiality

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.
3. Terminate the consultation at any time.

5. Alternatives to Telemedicine Consultation

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. Emergent Consultation Responsibility

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. Billing Information

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

8. Opportunity for Questions

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. Appointment Confirmation Messages and Reminders

We offer appointment 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. Consent for Text Messages and/or Emails

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

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.

Income Verification and Fee Agreement

INCOME

OTHER INCOME:

Service Fees Covered by Medicaid

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

*Credit Card Payments are subject to a 3% processing fee.

Authorization and Agreement

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 publicly 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.

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, and 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 changes in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.