General Patient Consent Forms

    Partners Family Medicine Practice & Recovery Center

    PRIMARY CARE CLINIC CONSENT FORM

    I hereby voluntarily consent to outpatient care from the Primary Care Clinic at Partners Family Medicine Practice & Recovery Center encompassing routine diagnostic procedures, examination, and medical treatment including (but not limited to) routine laboratory work and administration of medications as prescribed by the Providers. I further consent to the performance of those diagnostic procedures, examinations, and rendering of medical treatment by the Primary Care Clinic at Partners Family Medicine Practice & Recovery Center's medical providers and staff, as is necessary in the medical staff's judgment. I understand that during treatment, health care workers may be exposed to the patient's blood and/or body fluids increasing their risk of contracting Hepatitis B, Hepatitis C, and/or HIV. In the event an exposure occurs, I understand the need for testing for these diseases and I agree to such testing of myself to promote the health and welfare of the health care worker. I understand that this consent will be valid and remain in effect if I attend the clinic. I am aware that my medication list and controlled medication list from the PMP will be shared with the Lab Director for specimen result analysis when indicated.

    I hereby give authorization to utilize Telehealth services via HIPPA secured communication devices at Partners Family Medicine Practice & Recovery Center. I authorize my communications via online, audio, visual, or telephonic technology. I understand that I will be asked to Identify myself via a two-factor identification method which could be name, date of birth, last 4 of social security number, address, zip code, email, or telephone number and/or security questions. If at any time I make the decline to utilize Telehealth communication for my appointments or treatment plan services, I agree to provide this decline of service via writing.

    I hereby authorize the Primary Care Clinic at Partners Family Medicine Practice & Recovery Center to release any information acquired during my examination and treatment to any authorized agent for the purposes of healthcare, treatment, and payment. I authorize the release of medical information to my insurers as necessary for determination and payment of benefits; to healthcare providers involved in my care; to utilization review and professional standards review organizations, companies, and community resources that assist me with my healthcare needs.

    I have received the Partners Family Medicine Practice & Recovery Center Notice of Privacy Practices and Patient Rights.

    I hereby authorize the Primary Care Clinic at Partners Family Medicine Practice & Recovery Center to access historical prescription drug information.

    Partners Family Medicine Practice & Recovery Center

    I understand that the Primary Care Clinic shall not be liable for loss or damages of any personal property.

    The Primary Care Clinic endorses, supports, and participates in electronic Health Information Exchange (HIE) to improve the quality of your health and healthcare experience. HIE provides us with a way to share securely and efficiently patients' clinical information electronically with other physicians and health care providers that participate in the HIE network. Using HIE helps your health care providers to more effectively share information and provide you with better care. The HIE also enables emergency medical personnel and other providers who participate in the HIE program and who are treating you, to have immediate access to your medical data that may be critical for your care. Making your health information available to your health care providers through the HIE can also help reduce your costs by eliminating unnecessary duplication of tests and procedures. However, you may choose to opt-out of participation in the HIE, or cancel an opt-out choice, at any time by completing the appropriate form which will be provided upon your request. Partners Family Medicine Practice & Recovery Center endorses, supports and participates in the Immunization and Information System.

    I acknowledge that my health care information will be shared with the Regional Data Base for Immunization and Information System. You may choose to opt-out of participation in the CIIS system or cancel an opt-out choice. This notification must be in writing and may be presented at any time.

    I authorize the Primary Care Clinic at Partners Family Medicine Practice & Recovery Center to file a claim with my insurance carrier for services rendered. I authorize payment of medical benefits by any insurance carrier to either the Clinic or myself. I understand that insurance is a contract between myself and my insurance carrier. The Primary Care Clinic is not a party of this contract. We will bill your insurance carrier as a courtesy to you. In order to properly bill your insurance carrier we require that you disclose all insurance information including primary and secondary insurance cards, as well as, any change of insurance information within 60 days of service. Failure to provide complete insurance information may result in patient responsibility for the entire bill. It is the insurance company that makes the final determination of your eligibility and benefits. It is your responsibility to determine if your insurance company is contracted with us. If your insurance carrier is not contracted with us, you are responsible to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If your insurance carrier pays you directly, you are responsible for payment and agree to forward the payment to us immediately. All copayments, coinsurances, and deductibles may apply. Copayments are the patient's responsibility at the time services are rendered. If you are uninsured, please note that your account is your responsibility. No patient will be denied emergency treatment due to his/her inability to pay. Discounts for essential services are offered dependent on income and household size as compared to the current federal poverty guidelines. Please inquire for more details. The parent or legal guardian of a minor patient (under 18 years of age) is responsible for payment on the minor's account. Regardless of any personal arrangements that a patient might have outside of our office, if you are over 18 years of age or older and receiving treatment, you are ultimately responsible for payment of the service. Our office will not bill any other personal party. I understand that hospital services (i.e. laboratory tests and diagnostic images such as X-ray, CT, US, and MRI) are billed separately by the hospital and therefore not included in our charges. Clinic discounts do not apply to hospital bills.

    The patient will need to contact the hospital regarding charges and payments.

    • Notice of Privacy Practices: I have already received this information

    • HIPAA Consent: I have already received this information

    • Advanced Directives: I have already received this information

    I understand that I may revoke this consent in writing; except to the extent that the organization has already taken action in reliance thereof. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me.

    My signature below indicates that I understand and accept the content of this form.







    NOTICE OF PRIVACY PRACTICES

    This notice describes how information about you and your treatment may be used and disclosed and how you can get access to this information. Please review it carefully.

    • This notice describes the privacy practices of Partners Family Medicine Practice & Recovery Center. We are required by law to maintain the privacy and confidentiality of information about your health, health care, and payment for services related to your health (referred to in this notice as "protected health information" or "information") and to provide you with this notice of our legal duties and privacy practices with respect to your protected health information. When we use or disclose this information, we are required to abide by the terms of this notice (or other notice in effect at the time of the use or disclosure).

      • Protected Health Information in connection with alcohol or drug services:

      • 42 CFR Part 2 protects your health information if you have applied for or are receiving services (including diagnosis or treatment, or referral) for a substance use disorder. If you are applying for or receiving services for substance abuse, we may not acknowledge to a person outside the agency that you attend the agency or disclose any information identifying you as a substance user except under certain circumstances that are listed in this notice.

      • All Protected Health Information, including alcohol or drug services:

      • The Health Insurance Portability and Accountability Act ("HIPAA") Privacy Regulations (45 CFR Parts 160 and 164), also protect your health information whether or not you have applied for or are receiving services substance use.

    • Generally, we may use or disclose your protected health information when you give your authorization to do so in writing on a form that specifically meets the requirements of the laws and regulations that apply.

      • There are some exceptions and special rules that allow for uses and disclosures without your authorization or consent. They are listed in sections Ill and IV.

      • You may revoke your authorization except to the extent that we have already taken action upon the authorization. If you are currently receiving care and wish to revoke your authorization, you will need to provide your clinician with a written statement.

      • Please be aware of the fact that a court with appropriate jurisdiction or other authorized third party could request or compel you to sign an authorization.

    • Even when you have not given your written authorization, we may use and disclose information under the circumstances listed below. This list applies to all protected health information, including the information we get when you are applying for or receiving services for substance use.

      • Treatment:We may use or disclose your protected health information for treatment purposes. Treatment includes diagnosis, treatment and other services, including discharge planning. For example, clinicians may disclose your health information to each other to coordinate individual and/or group therapy sessions for your treatment or information about treatment alternatives or other health-related benefits and services that are necessary or may be of interest to you.

      • Health Care Operations:We may use or disclose your protected health information for the purposes of health care operations that include internal administration and planning and various activities that improve the quality and effectiveness of care. For example, we may use information about your care to evaluate the quality and competence of our clinical staff. We may disclose information to qualified personnel for outcome evaluation, management audits, financial audits, or program evaluation; however, such personnel may not identify, directly or indirectly, any individual client in any report of such audit or evaluation, or otherwise disclose client identities in any manner. We may disclose your information as needed within Partners Family Medicine Practice & Recovery Center in order to resolve any complaints or issues arising regarding your care. We may also disclose your protected health information to an agent or agency which provides services to Partners Family Medicine Practice & Recovery Center under a qualified service organization agreement and/or business associate agreement, in which they agree to abide by applicable federal law and related regulations (42 CFR Part 2 and HI PAA). Health Care Operations may also include use of your protected health information for programs offered by Partners Family Medicine Practice & Recovery Center, such as sending you a post­treatment questionnaire.

      • Other allowable uses and disclosures without your authorization, aside from treatment and health care operations, include:

        • Appointment Reminders:We may contact you to send you reminder notices of future appointments.

        • Medical Emergencies:We may disclose your protected health information to medical personnel to the extent necessary to meet a bona fide medical emergency (as defined by 42 CFR Part 2).

        • Incompetent and Deceased Patients:In such cases, authorization of a personal representative, guardian or other person authorized by applicable state law may be given in accordance with 42 CFR Part 2.

        • Judicial and Administrative Proceedings:We may disclose your protected health information in response to a court order that meets the requirements of federal regulations, 42 CFR Part 2 concerning Confidentiality of Alcohol and Drug Abuse Patient Records.

        • Commission of a Crime on Premises or against Program Personnel:We may disclose your protected health information to the police or other law enforcement officials if you commit a crime on the premises or against program personnel or threaten to commit such a crime. We may only provide limited information specifically related to the incident.

        • Child Abuse/Neglect:We may disclose your protected health information for the purpose of reporting child abuse and neglect to the Department of Children and Families in the form of a 51a. Any further inquires made by DCF cannot be responded to without your written release of information.

        • Duty to Warn:Where the program learns that a client has made a specific threat of serious physical harm to another specific person or the public, and disclosure is otherwise required under statute and/or common law, the program will carefully consider appropriate options that would permit disclosure.

        • Audit and Evaluation Activities:We may disclose protected health information to those who perform audit or evaluation activities for certain health oversight agencies, e.g., state licensure or certification agencies, which oversees the health care system and ensures compliance with regulations and standards, or those providing financial assistance to the program.

        • Research:We may use or disclose protected health information without your consent or authorization if we meet appropriate regulations for research related purposes.

    • If you are not applying for or receiving services for drug or alcohol abuse, the rules governing the use and disclosure of protected health information are different from and less restrictive than the rules governing information involving drug and alcohol diagnosis, treatment and referral. The next section lists the additional allowable disclosures that may be made without your authorization if you are not applying for or receiving services for substance use. (This list does NOT apply to those persons applying for or receiving services for substance use):

      • Allowable disclosure when required by law. We may disclose your protected health information as required by state or federal law.

      • Allowable disclosure for health or safety. We may disclose your protected health information to avert or lessen a serious threat of harm to you, to others, or to the public.

      • Expanded allowable abuse reporting/investigation of abuse. We may disclose protected health information to a person legally authorized to investigate a report of abuse or neglect.

      • Expanded allowable public health and health oversight activities. We may disclose your protected health information for public health purposes and health oversight purposes including licensing, auditing or accrediting agencies authorized or allowed by law to collect such information, including, for example, when we are required to collect, report or disclose information about disease, injury, vital statistics for public health purposes or other information for investigation, audit or other health oversight purposes.

      • Expanded allowable disclosure for law enforcement activities. We may disclose protected health information to law enforcement officials in response to a valid court order or warrant or as otherwise required or permitted by law.

      • Expanded allowable disclosure to your legally authorized representative (LAR). We may disclose your health information to a person appointed by a court to represent or administer your interests.

      • Expanded allowable disclosure in judicial and administrative proceedings. We may disclose your health information pursuant to a valid court or administrative order, or in some cases, in response to a valid subpoena or discovery request.

      • Allowable disclosure to the Secretary of Health and Human Services. We must disclose your health information to the United States Department of Health and Human Services when requested in order to enforce the privacy laws.

      • Right to Receive Confidential Communications:

        Normally we will communicate with you through the phone number and /or address you provide. You may request, and we will accommodate, any reasonable, written request for you to receive your protected health information by alternative means of communication or at alternative locations.

      • Right to Request Restrictions:

        At your request, we will not disclose health information to your health plan if the disclosure is for payment of a health care item or service for which you have paid out of pocket in full. You may request additional restrictions on our use and disclosure of protected health information for treatment, payment and health care operations. While we will consider requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restrictions and you are currently receiving services, please contact your clinician.

      • Right to Inspect and Copy Your Health Information:

        You may request access to your clinical file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records and you are currently receiving services, please ask your clinician how to proceed. Once you are no longer receiving services, contact the Center in writing. If you request copies, there will be a charge for each page copied and you will be told the cost prior to the copies being made.

      • Right to Amend Your Records:

        You have the right to request that we amend protected health information maintained in your clinical file or billing records. If you desire to amend your records and you are currently receiving services, please contact your clinician. Once you are no longer receiving services, contact the Agency in writing. Under certain circumstances, Partners Family Medicine Practice & Recovery Center has the right to deny your request to amend your records and will notify you of this denial as provided in the HIPAA regulations. If your requested amendment to your records is accepted, a copy of your amendment will become a permanent part of the record. When we "amend," a record, we may append information to the original record, as opposed to physically removing or changing the original record. If your requested amendment is denied, you will be informed of your right to have a brief statement of disagreement placed in your records.

      • Right to Receive an Accounting of Disclosures:

        Upon request, you may obtain a list of instances that we have disclosed your protected health information other than when you gave written authorization OR those related to your treatment and payment for services, or our health care operations. The accounting will apply only to covered disclosures prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to May 23, 2020. If you request an accounting more than once during a twelve (12) month period, there will be a charge. You will be told the cost prior to the request being filled.

      • Right to Receive Notification of Breach:

        You will be notified in the event we discover a breach has occurred such that your protected health information may have been compromised. A risk analysis will be conducted to determine the probability that protected health information has been compromised. Notification will be made no more than 60 days after the discovery of the breach, unless it is determined by a law enforcement agency that the notification should be delayed.

      • Right to Receive a Paper Copy of This Notice:

        Upon request, you may obtain a paper copy of this notice.

      • For Further Information and Complaint,

        you may contact the center's compliance officer if you have questions and if you are concerned that we have violated your privacy rights, if you disagree with a decision that we made about access to your protected health information, or if you wish to complain about our breach notification process. You may also file a written complaint with the Department of Public Health's Health Care and Quality or the Bureau of Substance Abuse Services. Upon request, we will provide you with the correct address. We will not retaliate against you if you file a complaint.

      Violation of federal law and regulations on Confidentiality of Alcohol and Drug Abuse Patient Records is a crime and suspected violations of 42 CFR Part 2 may be reported to the United States Attorney in the district where the violation occurs.

      • Effective DateThis notice is effective on May 23, 2020

      • Right to Change Terms of This Notice:We may change the terms of this notice at any time. If we change this notice, we may make the new notice terms effective to all protected health information that we maintain, including any information created or received prior to issuing the new notice. If we change this notice, we will post the new notice in public access areas at our service sites. We will request that you sign a document acknowledging your receipt of the new Privacy Practices

      • Privacy Officer:You may contact Privacy Officer Ms. lreri at 850-905-0110.







    AUTHORIZATION TO RELEASE MEDICAL INFORMATION FOR PAYMENT

    I authorize release of my medical information to the insurance companies or parties that are or may be liable for all or part of the charges incurred by me at Partners Family Medicine Practice & Recovery Center, such as diagnostic and therapeutic procedures, which may include sensitive information, including drug/alcohol use and/or psychiatric conditions. This authorization shall be valid only for the period of time required to actually process payment claims, and to determine benefits entitlement.

    I hereby authorize payment directly to Partners Family Medicine Practice & Recovery Center, insurance benefits otherwise payable to me, not to exceed the balance due of the agency's regular charges. I understand I may be financially responsible to Partners Family Medicine Practice & Recovery Center for charges not covered by this authorization or insurance benefits.

    INSURANCE ELIGIBILITY & COLLECTION OF PAYMENT

    • Clients are required to notify the center of any changes in their insurance coverage.

    • Clients are responsible for charges as a result of not informing center of insurance changes.

    • The center has the right to cancel/reschedule appointments if the center has not been informed of change/loss of insurance.

    • Clients may be required to transfer to another clinician within the center if their insurance changes and their current clinician is not a contracted provider with their new plan.

    • Clients understand that a change in their insurance may result in the center's inability to continue to provide services. (Not all clinicians accept all insurances)

    COLLECTION OF COPA YMENTS

    • Copayments & Deductibles are due at the time of service. Cash, check and credit/debit cards are accepted at the center. If copay is not paid on date of service, a copayment agreement must be signed. Appointments may be held until balances are paid in full.

    • There is a fee for returned checks. If a c.heck is returned, all future payments must be made in cash or debit/credit.

    • Services may be suspended if a balance has accumulated that is 30 or more days overdue.

    • Clients with outstanding balances of 90 days or more may be turned over to a collection agency.

    I attest that if my health insurance is terminated for any reason during my treatment program with Partners Family Medicine Practice & Recovery Center, I will assume the cost of the office visits that I attended without health insurance coverage. I also understand that many insurance companies place restrictions on the number and frequency of urine drug testing. If my treatment results in exceeding these limits, I understand that I am responsible for the cost of these additional tests.







    HIPAA PATIENT CONSENT

    Partners Family Medicine Practice & Recovery Center, Inc. provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). A copy of Partners Family Medicine Practice & Recovery Center's Notice of Privacy Practices is available for your review at the front desk.

    By signing this form, you consent to our use and disclosure of protected health information according to the Notice of Privacy Practices. This Notice applies to all your medical information created or maintained by Partners Family Medicine Practice & Recovery Center. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care. This request must be done in writing. However, such a revocation will not be retroactive.

    • Protected health information may be disclosed or used for treatment, payment, or healthcare

    • The Practice reserves the right to change the Notice of Privacy Practices by law

    • The Practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions

    • The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease

    • The Practice may condition treatment upon execution of this consent

    My signature below indicates that I understand and accept the content of this form.







    HEALTHCARE INSURANCE WAIVER

    I attest that if my health insurance is terminated for any reason during my treatment program with Partners Family Medicine Practice & Recovery Center, I will assume the cost of the office visits that I attended without health insurance coverage. I also understand that many insurance companies place restrictions on the number and frequency of urine drug testing. If my treatment results in exceeding these limits, I understand that I am responsible for the cost of these additional tests.