Take the first step towards starting your treatment by completing these forms prior to your intake appointment!

This platform is HIPAA-compliant and your responses will be sent securely to our intake team. Please call us (808-538-0704 in Honolulu or 808-961-6822 in Hilo) if you have any questions about the following documents before submitting.

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YOU HAVE THE RIGHT AND THE OBLIGATION TO MAKE DECISIONS CONCERNING YOUR HEALTH CARE. This form acknowledges your consent to treatment. Your counselor can provide you with the necessary information and advice, but because this affects you, the decision-making or treatment planning process requires your participation. Please feel free to ask any questions or to ask your counselor to clarify areas of your program if it is not understood.

To assist you in making an informed decision concerning your treatment, your substance abuse counselor will explain the following to you:

1.Kū Aloha Ola Mau services offered, i.e. educational sessions, process groups, skill building activities and alternative forms of treatment available, their benefits and risk, and the benefits and risks of no treatment;

2. Anticipated results and benefits of the proposed treatment;

3. Risks and complications involved in the proposed treatment;

4. The time period this consent applies to;

5. The right to ask questions about the proposed treatment and have them answered;

6. The right to secure a second opinion prior to the giving of consent; and

7. The right to withdraw consent at any time.

 

Possible risks and benefits of treatment in the Kū Aloha Ola Mau OTP are:

1. You will be asked to share personal experiences with your counselor and other participants at times. While you are encouraged to share only to the extent you feel comfortable, some people find this to be difficult and disturbing while others find it to be a positive and liberating experience.

2. The counseling of the program will address addiction issues - - including alcohol, tobacco& other drugs - - intended to reduce the risk of multiple addictions or developing newaddictions.

 

Once given, your informed consent to treatment may be withdrawn at any time by stating such intention to your counselor. Otherwise, your informed consent will expire when your treatment has been terminated. Refusal to sign or withdrawal of consent may result in termination of services and discharge from the program.

By signing below, you agree that:

1.You understand this form;

2.You have received all the information you want about your treatment plan;

3.You have given us your permission to carry out the treatment plan;

4.You have been given a copy of your rights as a consumer

 

Time period to which this informed consent applies: 

Telehealth involves the use of electronic communications to enable health care providers to interact with haumana at a site of the haumana’s choosing, for the purpose of improving care, access, and convenience.

Electronic systems used at Kū Aloha Ola Mau incorporate network and software security protocols to safeguard data and protect the confidentiality of haumana personal information.

Expected Benefits:

• Improved access to care by enabling a haumana to remain in their home or location convenient to the haumana .
• More efficient services.

Possible Risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of video) to allow for appropriate assessment by the provider
• Delays in treatment could occur due to deficiencies or failures of the equipment.
• In very rare instances, secur ity protocols could fail, causing a breach of privacy of personal information.
• The choice of location chosen by the haumana may not be secure (e.g. using public wifi, or in a location able to be seen or heard by another person in the physical proximity), which may lead to a breach of personal information.

I agree to be mindful of my surroundings and to choose an electronically secure, physically isolated location with which to engage in the treatment. I will not allow outside individuals into my space while in session.

I understand that same HIPAA and 42 CRF Part 2 rights apply to these encounters as in-person visits.

I understand that all the same standard treatment r equirements – e.g. monthly urine drug screens – still apply to all haumana regardless of whether encounters occur by telehealth or in person.

I understand that telehealth encounters will be billed similarly to an in-person encounter and any co-payments required at in-person visits will also be charged for telehealth appointments.

I understand that the use of telehealth services is a privilege and may be utilized or discontinued at my provider’s discretion to best support my recovery.

I agree to have my video and audio on for the entirety of the session and to actively engage.

I agree to avoid distractions like eating, drinking, smoking, or driving during session.

I understand the information presented on this form, and I agree to participate in ongoing telemedicine consultation.

TUBERCULOSIS CLEARANCE PROCEDURE

I agree to complete tuberculosis screening through Kū Aloha Ola Mau or to provide documentation of current (within the last 12 months) TB screening results prior to the intake physical. I understand that the TB Clearance form used at Kū Aloha Ola Mau is provided by the State of Hawaii and is in compliance with the Department of Health TB Clearance Manual.

HEPATITIS SCREENING

Kū Aloha Ola Mau and the Hep Free Hawaii Program is making both hepatitis B and hepatitis C screening available to all Haumana entering into our buprenorphine and methadone treatment.

HIV/AIDS EDUCATION

Kū Aloha Ola Mau requires that all Na Haumana entering buprenorphine and methadone treatment receive HIV/AIDS education and to be referred to HIV antibody testing. By signing this document, I agree to participate in HIV/AIDS education annually.

have read and understand this education agreement form.

USE OR DISCLOSURE OF HEALTH INFORMATION

By signing this form, I authorize the diclosure/acquirement of my protected health information maintained by:

Ku Aloha Ola Mau

Forms of information (initial all forms in which consent applies):

This consent may be revoked at any time, upon notice of the person who has signed below, except when action has already been taken. Without revocation, this consent will expire one year from date of signature.

The types of medical information above cannot be released without my specific consent and knowledge. I hereby release Kū Aloha Ola Mau and its staff from all liability and all claims of any nature pertaining to the disclosure of information of any professional opinions, findings, or recommendations contained in these records.

Redisclosure is prohibited This information has been disclosed to you from records protected by Federal (42 CFR part 2), Federal Health Insurance Portability and Accountability Act (HIPAA 45 CFR, parts 160 & 164), and State (HRS 325-101) confidentiality rules. The Federal rules and State law prohibit further disclosure of this information unless further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2, HIPPA, and HRS 325-101. A general authorization for the release of medical or other information is NOT sufficient for this purpose. Revised: April 2007 Rev: 3/2011 MQ; 8/2012 MQ

hereby authorize

and

to communicate with and disclose to one another the following information from my record:

Presence in Treatment, Drug test results, Financial information, to include my completion of a Financial Hardship Form from S&G Labs Hawaii, LLC to help determine my financial hardship for any out of pocket payment I need to cover.

THE PURPOSE OF DISCLOSURE AUTHORIZED HEREIN IS SPECIFICALLY FOR:

Communicating and updating my insurance information and or financial status in order to have S&G Labs Hawaii, LLC bill my urine drug screens to my insurance company.

I understand that my alcohol and/or drug treatment records are protected under Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. Parts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows.

Expires on patient discharge.

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

Understanding Your Health Record/Information:

Kū Aloha Ola Mau must keep information about your health care confidential. Information regarding your health care is protected by two federal laws: the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d et Kseq., 45 C.F.R. Parts 160 & 164, and the Confidentiality Law, 42 U.S.C. §290dd-2, 42 C.F.R. Part 2. Under these laws, Kū Aloha Ola Mau may not tell anyone that you attend or have ever attended a substance abuse program, nor may Kū Aloha Ola Mau give out any information identifying you as an alcohol or drug abuser, or give out any other health information about you without your authorization, except as described in this notice or required by law. In addition, State laws and Administrative Rules under H.R.S. §334-5 and HAR 11-175-31 may give more protection to PHI maintained by Kū Aloha Ola Mau. In such situations, Kū Aloha Ola Mau will follow the more stringent laws. Your health record contains your symptoms, examination and test results, diagnoses, treatment (e.g. outpatient counseling) and a plan for future care or treatment. This information serves as a:

• Basis for planning your care and treatment;
• Means of communication among the many health professionals who contribute to your care;
• Legal document describing the care you received;
• Means by which you or a third party payer can verify that services billed were actually provided;
• A tool in educating health care professionals;
• A source of data for health research;
• A source of information for public health officials charged with improving the health of the nation;
• A source of data for facility planning; and
• A tool with which your treatment provider can assess and continually work to improve the care he or she render s and the outcomes he or she achieves.

Understanding what is in your record and how your health information is used helps you to:

• Ensure its accuracy;
• Better understand who, what, when, where and why others may access your health information;
• Make more informed decisions when you agree to give information to others.

Your health information rights:

Kū Aloha Ola Mau collects limited information about you and does not maintain your health records. Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to review your complete health information. Your health information is available from your substance abuse treatment program. You have the right to ask your treatment program to:

• Limit the use and/or disclosure of your medical information as provided by 45 C.F.R. §164.522;
• Obtain a paper copy of this notice of information practices upon request;
• Inspect and copy your health record as provided for in 45 C.F.R. §164.524;
• Amend your health record as provided in 45 C.F.R. §164.526
• Obtain an accounting of the disclosure of your health information during the six years prior to your request as provided in 45 C.F.R. §164.528;
• Request communications of your health information by alternative means or at alternative locations;
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

You also have the right to give permission for most uses of your health information. There are stricter Federal and State requirements for use and disclosure for some types of protected health information, for example, mental health, substance abuse, developmental disabilities, and Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), and AIDS - Related Complex (ARC) information. However, there are still limited circumstances in which these types of information may be used or disclosed without your authorization.

Ku Aloha Ola Mau responsibilities:

Ku Aloha Ola Mau pays for substance abuse treatment using State and Federal money. Ku Aloha Ola Mau is required to:

• Maintain the privacy of your health information by law;
• Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you;
• Abide by the terms of this notice.

We reserve the right to change our practices and to m ake the new provisions effective for all protected health information we maintain. Should our information pr actices change, w e will mail a revised notice to the program that provided your treatment within sixty (60) days.

Examples of disclosures for payment and health operations:

Kū Aloha Ola Mau will use your information for payment.

For example: Your substance a buse treatment program will send a bi ll to Kū Aloha Ola Mau that may contain information that identifies you, as well as your diagnosis and treatment. Kū Aloha Ola Mau will then use this information to pay the treatment program. Your health information is available from your substance abuse treatment program. In situations where Kū Aloha Ola Mau must use your Protected Health Information (PHI) for bi lling pur poses, you have the option to self-pay for your treatment. Ho wever, if you decide not to self-pay, you will have to authorize the release of your PHI for purposes of payment.

ADAD may use your health information for day-to-day treatment program operations.

For example: Kū Aloha Ola Mau staff may use information in your health record to assess the care and outcomes in your case and others like it and to justify funding from the state and federal government. This information w ill then be used in an effort to improve continually the quality and effectiveness of the healthcare and service your treatment program provides.

Other uses and disclosures not requiring your permission:

Business Associates: There are some services provided for Kū Aloha Ola Mau through contracts with bus iness associates. Examples include an auditor who reviews Kū Aloha Ola Mau records for financial accountability.

Public Health: As required by law, we may disclose your health information to public health or legal authorities preventing or controlling disease, injury or disability.

Health Oversight: Federal and State laws allow for your health information to be released to investigate fraud and abuse, for licensing and for program quality.

Imminent Danger: Suspected child or elder abuse or intention to harm oneself or another person can be reported to local authorities without your consent.

For more facility information or to report a problem:

If you have questions or would like to report a problem, you may contact the Kū Aloha Ola Mau Privacy Contact, 1130 N. Nimitz Hwy., Suite C302, Honolulu, Hawai‘i 96817, 808 538-0704.

If you believe your privacy rights under 45 C.F.R have been violated, you can file a written complaint with the Kū Aloha Ola Mau Privacy Contact or with the United States Department of Health and Human Services—Office of Civil Rights, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, DC 20201. There will be no retaliation for filing a complaint.

Violation of the Substance Abuse Confidentiality Law, 42 U.S.C. §290dd-2, 42 C.F.R. Part 2 by a program is a crime. Suspected violations of the Confidentiality Law may be reported to the ADAD Privacy Contact or with United States Attorney in the district where the violation occurs. There will be no retaliation for reporting a violation.

My signature below indicates that I have been provided with a copy of the Notice of Privacy Practices.

THIS NOTICE IS AVAILABLE IN BIGGER PRINT UPON REQUEST.

As a Haumana, I have:

• The right to treatment and services under conditions that support my independence and restrict such independence only as necessary to comply with the law, court orders, and as needed for good treatment.
• The right to a written treatment plan to be develope d within 30 days from admission that fits my individual needs. My treatment will be based on the treatment plan with set times for review. Any revisions will be appropriate to my treatment needs.
• The right to ongoing participation in the planning, development and revision of my treatment plan.
• The right to be provided with reasonable explanation of all aspects of my own condition and treatment.
• The right to refuse treatment except during emergency situations or as permitted under law in the case of a person committed by a court for treatment.
• The right not to participate in experimentation without my informed, voluntary, written consent and the right to appropriate protection with such participation. The right and oppor tunity to change my mind about such consent.
• The right to be treated as a human being in a place that is safe and private.
• T he right to confidential treatment of my records. The right to access my own substance abuse records upon request.
• The right to be informed promptly in language and terms that I understand of the rights described in this section
• The right to grieve with respect to infringement of what is written here, including the right to have such grievanc es considered in a fair, timely and impartial procedure.
• The right to exercise these rights without it being held against me, including reprisal in the form of denial of any appropriate available treatment.
• The right to the least restrictive level of services with residential treatment being the most restrictive and outpatient treatment being the least.

I hereby certify that I fully understand my rights and have been provided with a copy of this document.

QUEST health plans, Medicare, and some commercial health plans provide for full or partial reimbursement of methadone treatment. The rate of reimbursement depends on your specific plan and its coverage.

Treatment charges will be billed to my insurance plan as authorization from my counselor is received. Both medical and counseling services must be authorized for you to use benefits to pay for treatment at Ku Aloha Ola Mau.

RESPONSIBILITY STATEMENT

1. CHANGE IN PLAN OR STATUS – I am responsible for immediately informing the Ku Aloha Ola Mau counselor of any changes in my insurance plan, for example, ineligibility or change of plan.

2. NON-COVERAGE BY HEALTH PLANS – If for any reason my plan does not pay for medical or other treatment costs, I understand that I am financially responsible for my treatment at the self-pay rates listed below. I will be able to develop a payment plan with Ku Aloha Ola Mau if I so wish.

3. DISENROLLMENT AND / OR FAILURE TO RECEIVE AUTORIZATION – If I have been disenrolled from a plan and have not re-enrolled in another, I understand I am responsible to pay the daily, weekly or monthly rate until I have secured insurance coverage and Ku Aloha Ola Mau has received authorization to provide me with methadone treatment. If there has been duplicate coverage (from myself and the plan), I will be reimbursed by Ku Aloha Ola Mau for that specific amount and time of service.

4. NON-PAYMENT – If I do not meet payment obligations I will be in non-compliance with my treatment plan goal/objectives and Ku Aloha Ola Mau policy. If one payment is missed a $10 late fee will be assessed; if two consecutive payments are missed I will be discharged from the program; if on the methadone program this discharge will follow a 10-day detox.

 

FEE SCHEDULE

Intake – Methadone, Buprenorphine, or Cornerstone with medical assessment: $225

Intake – Cornerstone, without medical assessment: $127

Methadone Program: $575 monthly; or $133 weekly (includes all methadone, individual counseling, and group therapy)

Annual Physical Exam: $100

Physician Office Visit: $75 for 15 minutes, $100 for 30 minutes

Individual Counseling (1 hour): $90

Group Therapy (1 hour): $51

Psychiatric Assessment: $250

have read, understand, and received a signed copy of the Financial Responsibility form. I was provided with the opportunity to ask questions about sections I did not fully understand. I understand that my signature will remain in effect throughout my current treatment episode at Kū Aloha Ola Mau.

USE OR DISCLOSURE OF HEALTH INFORMATION

By signing this form, I authorize the diclosure/acquirement of my protected health information maintained by:

Ku Aloha Ola Mau

1130 N. Nimitz Hwy C-302
Honolulu, HI 96817
(808) 538-0704
 
900 Leilani Street
Hilo, HI 96720
(808) 961-6822

My health information may be disclosed to:

Forms of information (Initial all forms in which consent applies):

Other important information

This consent may be revoked at any time, upon notice of the person who has signed below, except when action has already been taken. Without revocation, this consent will expire one year from date of signature.

The types of medical information above cannot be released without my specific consent and knowledge. I hereby release Kū Aloha Ola Mau and its staff from all liability and all claims of any nature pertaining to the disclosure of information of any professional opinions, findings, or recommendations contained in these records.

Redisclosure is prohibited This information has been disclosed to you from records protected by Federal (42 CFR part 2), Federal Health Insurance Portability and Accountability Act (HIPAA 45 CFR, parts 160 & 164), and State (HRS 325-101) confidentiality rules. The Federal rules and State law prohibit further disclosure of this information unless further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2, HIPPA, and HRS 325-101. A general authorization for the release of medical or other information is NOT sufficient for this purpose. Revised: April 2007 Rev: 3/2011 MQ