Patient Intake

Patient Intake - Opioid or Alcohol Abuse

APPLE RIDGE TREATMENT CENTER
Welcome to Apple Ridge Treatment Center. Our goal is to help you with your recovery from opioid and/or alcohol abuse. We offer two programs in the office. One, an oral treatment called Suboxone film. Second, a once a month intramuscular injection called Vivitrol. Please fill out the following forms in their entirety. Once submitted, a cooridinater will call you to set up your appointment.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Social Security Number
Best Daytime Phone Number *

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Email - We do offer private patient portal capabilities. We will activate your portal and send you instructions.
Valid Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Take a Photo of your Valid Driver's license or State Photo ID. (If you do not have one, call the office. You will not be able to proceed with online forms) *
I agree that the above information is true to my knowledge. I will inform Apple Ridge Treatment Center immediatley should any information change. I understand failure for the office to contact me due to inappropriate information can affect my treatment. *

I agree.
Today's Date *

Month Day Year
Date
Signature of patient or if minor, parent/guardian *

Clear

Patient Financial Responsilbility

Apple Redge Treatment Center Policy
Apple Ridge Family Medicine appreciates the confidence you show in choosing us to provide for your health care needs. The services you have elected to participate in, implies a financial responsibility on your part. The responsibility obligates you to ensure payment in full of your fees. As a courtesy, we will bill your insurance carrier/s on your behalf. However, you are ultimately responsible for payment in full of your bill.

Many insurance companies have additional stipulations that may affect your coverage. It is ultimately the patients/guarantor’s responsibility to know your coverage benefits. I authorize Apple Ridge Family Medicine to furnish information to insurance carriers concerning my care. You are responsible for any amounts not covered by your insurance. If your insurance carrier denies any part of your claim, or if you elect to continue services past your coverage/policy period, you will be responsible for your balance in full.

You are responsible for the payment of any deductible, co-payments/coinsurance as determined by your contract with your insurance carrier. Some health insurance carriers require the patient to pay a co-pay for services rendered. This is a contract between you and your insurance carrier. Payment of all co-pays is expected at the time of service is rendered for the patient. If you do not have the co-pay, you may be asked to reschedule.
Coinsurance,deductible and non covered items are due 30 days from receipt of firststatement. I understand that the return check fee is $25.00 *

I Understand
I understandthat I am responsible for co-payments and deductible/coinsurance as dictated bymy insurance carrier. *

I Understand
I fully understandthat I am ultimately responsible for all changes associated with my account andthat if I fail to pay any amount due, I will also be responsible for allcollection fees, court cost, attorney fees and any other charges incurred inthe collection of any balance due. I further understand that a fee of, as muchas 25%, will be added to my total account balance in accordance with thisfacility's contract with it's collection agency. I understand that I will bedischarge from the practice for financial non compliance.

I Understand
Today's Date *

Month Day Year
Date
I have read theabove policy regarding my financial responsibility to Apple Ridge FamilyMedicine, for providing medical services to me or the above-named patient. Icertify that the information is, to the best of my knowledge, true andaccurate. I authorize my insurer to pay any benefits directly to Apple RidgeFamily Medicine. I understand that any amount remaining after such payment hasbeen made by my insurance carrier becomes the patient's responsibility. SignBelow. *

Clear

Authotization To Leave Personal Health Information By Alternate Means

Hipaa Policy
From time to time it may be necessary for a representative of Apple Ridge Family Medicine to contact patients for various notification purposes that could include disclosure of Protected Health Information such as:

·       Appointment reminders/confirmation/rescheduling

·       Prescription renewal/reminder information

·       Lab/Imaging test results

·       Requests to call the doctor for other issues

We would like to know how we can contact you and with whom we can leave a message or share other information about your Protected Health Information.
I authorizeApple Ridge Family Medicine physicians and/or staff to contact me and leavemessages that could include Protected Health Information pertaining to my careby the methods I have selected below. I authorize Apple Ridge Family Medicineto leave detailed, personal health information by the following means. (Chooseall that apply) *

Daytime phone/voice message Secondary phone/voice message Email
*If I have authorized contact via email, I understand that the message may not be encrypted and therefore security from an unauthorized access cannot be guaranteed. I further understand that Apple Ridge Family Medicine cannot guarantee receipt of message.
Authorization to Share Personal Health Information with Certain Individuals
Name of Permitted Individual

First Name Last Name
Enter relationship
Phone Number of Individual

Area Code Phone Number
Name of Permitted Individual

First Name Last Name
Enter Relationship
Phone Number of Individual

Area Code Phone Number
I do not wish to list anyone to have access to my Private Health Information

I Agree
Today's Date *

Month Day Year
Date
With mySignature Below, I acknowledge and understand that this Authorization will bekept as part of my medical record and that the communication instructionslisted above will remain in effect until revoked by me in writing. It is myresponsibility to notify Apple Ridge Family Medicine in writing should I wishto change any of information noted above and to notify Apple Ridge FamilyMedicine if my contact information changes. *

Clear

No Show or Improper Cancellation Policy

Apple Ridge Treatment Center
We understand that things happen where you can’t make your appointment. We do ask for a 24 hour notice in cancellations and rescheduling’s. If you do not show for your appointment, please note this is how Apple Ridge will handle no shows and improper notice of cancellations.

You are allowed the following within a 365 day period. The policy resets 365 days from the first offense.

·       Your first ‘No Show’ is a verbal warning. One of our staff members will call you and alert you to the no show. If this is an improper cancellation notice, you will receive the verbal warning at the time of your phone call.

·       Your second ‘No Show’ or improper cancellation notice would be a charge of $50 dollars. You would be verbally notified of this charge.

·       Your third ‘No Show’ or improper cancellation notice would result in a discharge from the practice. This is not guaranteed to be told you verbally. You would receive a letter within 3-4 business days of the third ‘No Show’. That letter explains to you the policy and that you will receive thirty (30) days of emergency care by the practice. This would be the time we advise you to search for another physician.

Please note we have a policy that if you arrive 10 minutes late for an appointment, you will be asked to reschedule. This does not fall into the ‘No Show’ or improper cancellation notice policy. We will simply need to reschedule your appointment. We will do our best to accommodate you based on the physician’s schedule. This policy is in place to not disrespect other patient’s appointment times.
Today's Date *

Month Day Year
Date
I understand the above policy. Sign Below *

Clear

Controlled Substance Medication Management Agreement

Apple Ridge Treatment Center
WHAT YOU SHOULD KNOW:

The medicine your health care provider has talked to you about is called a controlled substance. A controlled substance has the potential to be abused. Your healthcare provider wants you to be safe while you take this medicine. This agreement helps you to know what you should and should not do while taking this medicine. It helps your healthcare provider and you follow the law. It applies to all controlled substance prescriptions this practice gives you.

Note: For children with ADHD, treatment decreases the risk of substance abuse. ADHD medication has the potential for abuse, misuse and addiction if NOT taken appropriately as prescribed.

INSTRUCTIONS:

This agreement is like a contract. Please read all of this agreement first. Then write your initials on the blank lines next to each item. You will sign the agreement on the last page. You may ask any questions you have before signing the agreement. When you sign it, it means you understand everything you have read. It also means all of your questions were answered.

You may decide you do not want to sign this agreement. If you do not sign it your healthcare provider will not be able to give you a prescription for a controlled substance.

Note: initial fields with prefix * may be marked N/A if the form is only for ADHD medication.

USING A CONTROLLED SUBSTANCE SAFELY AND LEGALLY

Carefully Read the statements below.

I will take this medicine exactly how my healthcare provider instructs me to take it.

I am the only person who will take this medicine. I will not share this medicine with anyone.

I will keep this medicine in a place where no one other than me can get it.

  I will file a police report if this medicine is lost or stolen. I will tell my healthcare provider and give

the office a copy of the police report. My provider may or may not give me more medicine.

* In most states, driving while taking this medicine (excluding ADHD and wakeful medications) is considered driving under the influence (DUI).

I will call my healthcare provider within 2 days if another healthcare provider gives me a controlled substance. This includes the hospital or the ER.

I might be asked to take a urine or saliva (pee or spit) drug test while I am taking this medicine. I may have to pay for the test.

I may have to bring this medicine to my health provider’s office for a pill count. This means this medicine will be counted by my healthcare provider or another provider in the office.

· This includes notification of certification for medical marijuana and proof of certification must be presented to the office.

· If medical marijuana is started other controlled substances may be weaned or stopped.

If I do any of the following, my healthcare provider may not refill this medicine:

· Take someone else’s medicine.

· Fail to take or use my medicine as instructed by my healthcare provider.

· Use, sell, possess, or transport any illegal drugs or other illegal substances. This includes marijuana.

· Misuse legal drugs or other legal substances. This includes alcohol.

· Try to get a controlled medicine from another healthcare provider.

  My healthcare provider checks the PA Prescription Drug Monitoring Program (PA PDMP) in accordance with PA law.

RISKS OF USING A CONTROLLED SUBSTANCE

Carefully Read the statements below.

This medicine may not help me or may help me only for a short time. My healthcare provider will talk with me about what is best for my health condition.

This medicine may have side effects. Some side effects are:

·                Feeling dizzy or headache
·                Feeling sleepy
·                Nausea or throwing up
·                Constipation (not ADHD)

·                ADHD only: increased heart rate

·                ADHD only: decreased appetite
·                Itching (not ADHD)

·                ADHD only: weight loss
·                Trouble concentrating (not ADHD)

·                ADHD only: stomach pain

*This medicine may have side effects that cause me harm or injury (NOT FOR ADHD). Some serious side effects are:

·                Breathing problems
·                Allergic reaction
·                Accidents
·                Slow to react
·                Brain changes
·                Trouble concentrating

*I have been told not to do the following activities while taking this medicine (EXCEPT IF ADHD MEDICINE)

· Use heavy equipment or power tools. This includes lawn mowers and chain saws.

· Drive. This includes cars, motorcycles, trucks, ATVs, boats, and other vehicles.

· Work in a high place without protection. This includes working on a ladder or on a roof.

·Take care of people who can't take care of themselves, like a baby.

* I might become tolerant to this medicine (EXCEPT PEDIATRIC ADHD MEDICATION). This means my body might get used to taking this medicine. I might feel like I need more medicine to help me.

* I might become dependent on this medicine (EXCEPT PEDIATRIC ADHD MEDICATION). This means my body might feel withdrawal if I do not take this medicine. Withdrawal might make me feel sleepy, grumpy, or like I have the flu. I might have an upset stomach or have trouble thinking.

* I might become addicted to this medicine (EXCEPT PEDIATRIC ADHD MEDICATION). This means I may "crave" this medicine even when my body does not need it. It can happen even if I have not been addicted before.

I am at higher risk to become tolerant, dependent, or addicted to this medicine if I have been addicted to anything before. I am also at risk if anyone in my family has been addicted before. This includes alcohol or marijuana.

If I feel like I am tolerant, dependent, or addicted to this medicine, I will tell my healthcare provider.

I am at risk for overdose if I take too much of this medicine. Overdose might also happen if I take other medicine or someone else's medicine while taking this medicine. I could die if I overdose.

My healthcare provider might decide I should stop taking this medicine if:

·                It is not helping my health condition.

·                I have serious side effects.

·                I become tolerant, dependent, or addicted. Or, if I overdose.

(Women Only) Taking this medicine while I am pregnant may hurt my baby. My baby could become dependent on the medicine. I will tell my healthcare provider and my OB/GYN if I am pregnant. I will also tell my healthcare provider and my OB/GYN if I think I am pregnant or want to become pregnant.

MY HEALTHCARE PROVIDER AND ME

Carefully Read the statements below.

My healthcare provider will help me to know which medicine is right for me.

I might need to see another healthcare provider to help me with my health condition. Examples are:

·                Physical therapist
·                Mental health
·                Specialist
I will come to every appointment. I might need to be seen in the office every 1 to 3 months while I am taking this medicine. This is to help keep me safe and healthy.

This medicine will only be refilled during my office visit or during regular office hours. It may take the practice 3 business days to refill my medicine.

This medicine will not be refilled early. It may take the practice 3 business days to refill my medicine.

My prescription will be eprescribed to the pharmacy. I understand under federal regulations, that my prescription will not be printed.

I will tell my healthcare provider all of my past and current health history, including:

·                Health conditions
·                Medicine I use now
·                Medicine I have used before
·                Alcohol use
·                Drug use
·                Allergies

I will ask my healthcare provider any questions I have about the medicine I take.

I will treat my healthcare provider and all staff with respect as I will expect to be treated with the same respect.

If there is a legal investigation about me possibly not following the law when using this medicine, I give consent to my healthcare provider to share information as required to follow all city, state or federal laws. When following these laws:

· My provider might share information with law enforcement, a pharmacy the Board of Pharmacy, or other healthcare providers.

· Information might include a copy of this agreement. It may also include my name and Other information that identifies me.

SIGNATURE

My signature below means the following:

· I have read all of this agreement or someone has read it to me. I understand this agreement.

· I have asked any questions I have about this agreement. My questions have been answered.

· I understand I must sign this agreement to receive controlled substances from my healthcare provider.

· I understand if I do not follow this agreement:

· This medicine may be stopped. If it is stopped, my provider may taper the medicine over several days.

· PinnacleHealth Medical Group might decide I can’t be a primary care patient anymore.

· If I am dismissed as a patient because I have not followed this agreement I waive any rights I have to any action against Apple Ridge Family Medicine.

· I understand I will receive a signed copy of this document upon request.
Today's Date *

Month Day Year
Date
Signature of patient, if minor, signature or parent/guardian, *

Clear

Medical Record Release Form

Apple Ridge Treatment Center
I authorize Apple Ridge Family Medicine, 1311 Biglerville Road, Gettysburg, PA 17307 to obtain my previous medical records. Please include my entire record from your facility, along with any old records you may have from previous physicians. The phone number to this facility is 717-334-8165 and the fax number is 717-338-9070.
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Please enter the name, adress and phone number of the previous treatment facility that Apple Ridge Family Medicine will be obtaining records from. *
Special Records: Include the following medical records ifsuch information is included in your records. Please check all boxes that may apply. Checking the boxes is not arepresentation that such information exists. *

Include Drug and Alcohol Treatment Records (protected by thePennsylvania Drug and Alcohol Abuse Control Act, 71 P.S. 1690.108) Include Mental Health Records (protected by the MentalHealth Procedure Act, 50 P.S. 7111) Include AIDS/HIV – Related Records (protected byConfidentiality of HIV- Related Information Act, 35 P.S. 7607) Include Sexual Abuse/Assault and Domestic ViolenceCounseling Records (protected by 42 Pa.C.S.A. 5945.1 and 23 Pa.C.S.A. 6116,respectively.)
Purpose of Release of Information : Cooridination of Substance Abuse Treatment

This authorization will expire in 1 year from date of Signature

I understand that I may revoke this authorization at any time by notifying my provider or by notifying the provider or entity that is authorized to receive this records. I understand that revocation will not have any effect on the actions taken prior to any revocation and will not apply to information that has already been released in response to this authorization.

The authorization is voluntary. I can refuse to sign this authorization.

I understand that if the organization authorized to receive the information is not a health plan or a health care provider, the information may no longer be protected by federal privacy regulations.

I understand that this information may be re-release by the recipient and no longer protected.

I understand that the provider named above may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.

If mental health records are being release as permitted by the Mental Health Procedures Act, I understand that I have a right, subject to 55 Pa. Code 5100.33 to inspect the material being released.

If AIDS of HIV- related information is being released, this information has been disclosed to you from records protected by Pennsylvania law. Pennsylvania law prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or is authorized by the Confidentiality of HIV- Related Information Act. A general authorization for the release of medical or other information is not sufficient for this purpose.

By signing below, I certify that I understand the nature of this release.
Today's Date *

Month Day Year
Date
By signingbelow, I authorize the release of the medical information requested andspecifically waive the confidentiality protection afforded by Pennsylvaniastatutory law for the Special Records indicated above. The waiver is applicable only to this request and is not meant to be a general waiver. *

Clear
Should be Empty:

Patient Intake - Opioid or Alcohol Abuse

Insurance Information

Patient Financial Responsilbility

Authotization To Leave Personal Health Information By Alternate Means

Authorization to Share Personal Health Information with Certain Individuals

No Show or Improper Cancellation Policy

Controlled Substance Medication Management Agreement

Medical Record Release Form