Medical records policy
I understand that my medical records are the property of Quest Center. Information may be shared among practitioners of Quest Center for purposes such as treatment or other health care operations, including but not limited to coordination of care in an integrated setting, quality assurance activities, utilization review activities, and peer review. If I am referred to practitioners outside of Quest Center, any necessary information may be shared with them as well, in order to facilitate and coordinate my health care; however, a release of information form will be required for this information sharing. In addition, Quest Center will provide necessary documentation to my insurance company for purposes of claims review and payment. All of this is done pursuant to my consent, as indicated by my signature at the bottom of this document.
Consent to release information
I consent to allow Quest Center to release my confidential health information for purposes of treatment, payment and health care operations. In particular, I consent to the release of my confidential health information for the following purposes: (1) for the diagnosis, treatment and/or evaluation of any health condition, including the sharing of information by and among Quest Center providers and outside health care providers; (2) as required by my insurance carrier for the purposes of reviewing and paying claims for services rendered by Quest Center providers; (3) for the performance of quality assurance, utilization review, and/or peer review activities; (4) for the determination of eligibility under my insurance health plan; (5) as required by any governmental agency or any entity responsible for processing or paying my claims for medical benefits, including Worker’s Compensation claims; and (6) as otherwise authorized by law. I understand that I may revoke my consent at any time, but action taken by Quest Center before that time will remain covered by this consent. I understand that information from my medical record may be reviewed or released while I am receiving care or after discharge and this information will be held confidential except as allowed by law.
I understand that Quest Center for Integrative Health will use and disclose health information about me.
I understand that my health information may include information both created and received by Quest Center, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.
I understand and agree that Quest Center may use and disclose my health information in order to:
- Make decisions about, and plan for, my care and treatment.
- Refer to, consult with, coordinate among, and manage along with other healthcare providers for my care and treatment.
- Determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care.
- Perform various office, administrative and business functions that support my clinician’s efforts to provide me with, arrange and be reimbursed for, quality, cost-effective health care.
I understand that if applicable, my health information, both created and received by Quest Center, may be used within the context of mandatory and necessary reporting related, but not limited to, statistics, funding or grants, that may be required by local, state and/or federal agencies.
I also understand that I have the right to receive and review a written description of how Quest Center will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of Quest Center, and my rights regarding my health information.
I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy of the most current version of Quest Center’s Notice of Privacy Practices in effect will be posted in the waiting/reception area.
I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that Quest Center is not required, by law, to agree to such requests.
Client Confidentiality Agreement
As a client of Quest Center, I may learn of confidential information relating to both potential and existing clients within an alcohol and drug recovery environment, as well as any other services that Quest Center provides inside and outside a clinical setting. I may be exposed to protected health information, including, but not limited to, general and specific client-related information, personal information, financial information that is related to employment or disability, or other information not generally disclosed by Quest Center to the public. This information may be in written or verbal form, electronically generated or created by any other means of transmission. Unauthorized access, discussion, review, disclosure, transmission, alteration, dissemination, or destruction of such information, except as required to fulfill the responsibility of Quest Center, is absolutely prohibited.
Purpose: To ensure that personal and protected health information is safeguarded so that individuals are not afraid to seek health care or other services that Quest Center may provide. To also ensure that personal health information is protected during its collection, use, disclosure, storage and destruction within Quest Center.
Definitions: Protected Health information is defined as all information recorded or exchanged that relates to an individual’s health, or health care history, including genetic information, about the individual, or the individual’s family.
Protected health Information is described as the following:
- Patient Name
- Patient Address
- City & County of Residence
- Zip Code
- Names of Relatives & Employers
- Birth Date
- E-Mail Addresses
- Social Security Number
- Medical Record Number
- Health Plan Beneficiary Number
- Account Numbers
- Telephone & Fax Numbers
- Vehicle or Other Device Serial Numbers
- Web URL’s
- Internet Protocol Addresses (IP)
- Finger or Voice Prints
- Photographic Images
Protected Health Information also includes conduct or behavior that may be a result of illness or the effect of treatment.
Policies: In accordance with this policy, I agree to protect and not to disclose confidential information. I agree that I have the responsibility to respect the confidentiality of the clients of Quest Center.
Office Policies
General: I am free to receive healthcare from any practitioners of my choice, either within or outside of Quest Center. As a patient of Quest Center, I will have the opportunity and choice to see one of Quest Center’s medical, mental health, substance use disorder, pain management, or HIV services providers, according to my identified health care needs. Practitioners at Quest Center are either independent contractors, supervised students/ interns/ or residents at, or employees of, Quest Center. Each practitioner is solely responsible for any health care decisions and recommendations he or she may make. While all practitioners will be practicing within the scope of their individual licenses, some of the treatments they discuss with me may be considered experimental, new, or “alternative”. I am solely responsible for deciding which treatment I will choose, although my provider(s) will assist me in reaching an informed decision. No guarantee is made as to the results that may be obtained from their examination or treatment.
After hours care: I understand that Quest Center recommends that I maintain a relationship with a primary care physician who can provide emergency care, since at this time, Quest Center does not offer emergency services. If an emergency arises, I agree to contact my primary care provider, call 911 or go to the nearest emergency room. If I have an urgent after-hours mental health issue, I will call the mental health crisis line at 503-988-4888, or call Quest Center’s after-hours mental health urgent care line at 503-484-4816. If an urgent after-hours medical issue arises, I may reach my Quest Center medical provider through the answering service at 503-402-2513.
Insurance billing and payment for services: If I choose to have Quest Center bill insurance for me, I understand Quest Center requires that my deductible be met and that my co- payment or my portion of the bill be paid at the time of each visit. In the event that my insurance carrier determines that the services provided to me are not a covered benefit under my health care plan, I am responsible for the total amount due, as well as any applicable co-payment or deductible. A $20 fee will be charged for any returned checks. I may choose to purchase any recommended nutritional supplements, health care products, books, etc. at this location or elsewhere. In most cases, non-prescription pharmacy items are not covered by insurance and I will need to provide payment for these items at the time I receive them. I am responsible for updating Quest Center on any changes in my insurance carrier or policy status, as well as any changes in my address, telephone number, name, email address, or other relevant information. My signature below authorizes payment of all insurance or health plan benefits to be made directly to Quest Center or its practitioners.
Medicare: At this time, most Quest Center practitioners are not authorized participating providers in the Medicare program and, therefore are unable to bill for or accept direct payment from Medicare. If, while I am a patient at Quest Center, I become eligible for Medicare, I must immediately inform the receptionist of this.
Workers Compensation: At this time, Quest Center practitioners are not accepting any worker’s compensation claims. I must notify my practitioner and Quest Center receptionist if my visit is due to an injury covered by Worker’s Compensation.
Past due accounts: I will be charged any necessary collection cost, including attorney’s fees or collection agency fees, both at trial and on appeal, and whether a lawsuit is filed.
Appointment Reminders Policy: Reminder calls are made to the best of our ability and as a courtesy. Clients are still expected to take responsibility for making, keeping, and managing all appointment times. Provider or program-specific orientation materials can provide more information on program- specific policies on responding to calls.