AUTHORIZATION TO GIVE MEDICAL CARE – CONSENT TO TREATMENT I hereby voluntarily consent to outpatient care from the Primary Care Clinic at ClearPath Family Healthcare 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 ClearPath Family Healthcare medical Providers and staff, as is necessary in the medical staff’s judgment.

I understand that during the course of treatment, health care workers may be exposed to the patients’ 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 as long as I attend the clinic.

I hereby authorize the Primary Care Clinic at ClearPath Family Healthcare Center to release any information acquired in the course of 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.

NOTIFICATION OF PRIVACY I have received the ClearPath Family Healthcare Center Notice of Privacy Practices and Patient
Rights.

AUTHORIZATION TO ACCESS RX HISTORY INFORMATION I hereby authorize the Primary Care Clinic at ClearPath Family Healthcare Medical Center to access historical prescription drug information.

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

HEALTH INFORMATION EXCHANGES The Primary Care Clinic endorses, supports, and participates in electronic Health Information Exchange (HIE) as a means to improve the quality of your health and healthcare experience. HIE provides us with a way to securely and efficiently share 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 TIP 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 HEALTHCURRENT HIE, or cancel an opt-out choice, at any time by completing the appropriate form which will be provided upon your request.

ClearPath Family Healthcare endorses, supports and participates in the Arizona Immunization and Information System (ASIIS). ASIIS is a confidential, computerized, system that collects and consolidates vaccination data for Arizonans of all ages and provides tools for designing and sustaining effective immunization strategies to prevent disease and reduce healthcare costs. Information in the ASIIS system can be released only to individuals; individual’s parent/legal guardian; individual’s healthcare provider; a school or child care center where the individual is enrolled; health insurers if financially responsible for immunizations; healthcare organizations; Department of Health Care Policy and Financing for individuals enrolled in Medicaid. You may choose to opt-out of participation in the ASIIS system or cancel an opt-out choice. This notification must be in writing and may be presented at any time.

CONSENT FOR TREATMENT: By this document, I do hereby request and authorize ClearPath Family Healthcare (CP), its medical practices and providers including physicians, technicians, nurses, and other qualified personnel, including appropriately supervised students and residents to perform evaluation and treatment services and procedures as may be necessary in accordance with the judgment of the attending medical practitioner(s).

I acknowledge that no guarantee can be made by anyone concerning the results of treatments, examinations or procedures. TREATMENT OF MINOR CHILDREN: I understand minor children patients must be accompanied by a parent or legal guardian. Charges for services rendered to minor children are the responsibility of the guardian who seeks treatment for the child and are due at time of service(s) regardless of court-ordered responsibility.

PHOTOGRAPHY/VIDEO: I acknowledge that my photograph may be taken for Chart identification and documentation purposes for my electronic health record and is the property CP unless I withdraw my consent in writing.

I consent to videotaping for a telehealth appointment for medical and medical record documentation purposes, provided said photographs or videotapes are maintained and released in accordance with protected health information regulations. I understand and agree not to photograph, videotape, audiotape, record or otherwise capture imaging or sound on any device. I also understand it is my responsibility to assure those accompanying me comply with this requirement. INSURANCE

AUTHORIZATION AND ASSIGNMENT: I request that payment of authorized medical benefits is made on my behalf directly to the CPC provider of service(s) furnished to me. I authorize CP to release any medical information to my health insurance carrier and/or its legitimate agents that is necessary to process related health insurance claims and/or to verify plan benefits in accordance with HIPAA health information standards. I authorize payment of service(s), otherwise payable to me under the terms of my private, group employer’s or group health insurance plan, directly to CP.

I hereby authorize that photocopies of this form to be valid as the original.

SELF-PAY PATIENTS: I understand if I do not have active coverage or choose not to utilize my insurance benefits, I responsible for all charges occurred at time of service.

PAYMENT GUARANTEE: I do hereby guarantee payment of all fees and charges related to all services and durable goods provided to me through CP medical practices and providers from my first date of examination or treatment. I agree to make full payment immediately upon receipt of a CP billing statement whether it is an interim or final bill. In the event that I fail to make full payment or fail to comply with other payment arrangements made with CP’s approval, I understand that appropriate collection measures may be initiated.

RESTRICTED SERVICE: I understand that all account balances must be in good standing prior to receiving additional services and will contact CP’s staff if I am unable to pay your balance. Past Due Accounts of 60 days or longer may be turned over to a third-party for collection, along with collection costs, attorneys’ fees and court fees. I also understand I may be discharged from the practice.

ADDITIONAL SERVICE CHARGES: Checks may be processed at time of service, if there are insufficient funds available, I understand I will be responsible for providing an alternate payment for the account amount, plus a $35.00 NSF fee.

ELECTRONIC HEALTH RECORD: I understand the following: Healthcare providers require access to patient medical information whenever or wherever a patient presents for care to assure safety, quality and to coordinate patient care across the provider network, avoiding duplication of services. CP has a system-wide electronic medical record that is available to caregivers on a “need to know” basis, to share information about patient care provided in the hospital, outpatient or physician office settings.

Confidentiality of records including those reflecting treatment for behavioral health issues, HIV/AIDS or drug or alcohol problems is maintained per relevant governmental and regulatory standards. Patient care summaries are automatically sent to designated CP and other community primary care/family/referring physicians, as well as to physicians who are consulted by the attending physician for coordination of care.

CP and/or the attending physician can furnish and release to federal and state healthcare oversight agencies, or upon written request, to all insurance companies or their representatives any information with respect to treatment of the patient herein named including copies of the medical record.

I give permission to share my electronic medical record among my healthcare providers and obtain medication history through a Provider Health Information Exchange (HIE). CP will follow state and federal laws regarding the access by medical providers of any sensitive information, such as behavioral health, substance abuse treatment, sexual abuse, genetic test results, HIV/AIDS status and adoption records. If I have provided my e-mail address, I am requesting the ability to access my medical information through the ClearPath Family Healthcare on-line Patient Portal.

ELECTRONIC PRESCRIBING: I understand that CP medical practices and offices may use an electronic prescription system which allows prescriptions and related information to be electronically sent between my CP providers and my pharmacy. I have been informed and understand that CP providers using the electronic prescribing system will be able to see information about medications I am already taking, including those prescribed by other providers. I give my consent to my CP providers to see this health information.

CONSENT FOR VIRTURAL HEALTH/TELEMEDICINE SERVICES: I hereby consent to engaging in virtual health or telemedicine services, where available, as part of my treatment. I understand that “virtual health” or “telemedicine services” includes the practice of health care delivery, diagnosis, consultation, treatment, transfers of medical data, and education using interactive audio, video, or data communications when the health care provider and patient are not in the same physical location. The interactive electronic systems used for these services will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption. I understand that the potential benefits of receiving care in this manner include improved access to care and the ability to obtain the expertise of a distant specialist. The potential risks include problems with information transmittal, including but not limited to poor data transfer which may include a poor video and data quality experience, or lack of access to my complete medical record by the remote physician. I understand that all information, including images, will be part of my medical record available to me if requested and with the same restrictions on dissemination without my consent. I understand I may withdraw my consent at any time.

IMMUNIZATION REGISTRY: I understand that CP participates in the Arizona Dept. of Health’s statewide immunization registry that collects vaccination history and information to serve the public health goal of preventing the spread of vaccine preventable diseases. The registry complies with federal health information privacy laws.

I do hereby grant permission for CP to send or fax childhood immunization records to schools, upon request.

CELL PHONES: I hereby consent to provide my telephone number(s), including my wireless telephone number(s), so that representatives from the CP, its successors or assigns can contact me in any manner including but not limited to by manually placing a call, by using an automatic telephone dialing system or an artificial or prerecorded voice, by texting, or by e-mailing, regarding any matter, including but not limited to my medical treatment, prescriptions, insurance eligibility, insurance coverage, scheduling, billing or collection matters. This consent includes any updated or additional contact information that I may provide. I understand that I will be able to change my preference at any time

RELEASE OF RESPONSIBILITY FOR PERSONAL VALUABLES: I have been made aware and understand that all CP medical practices and offices provide no facilities for safekeeping of valuables. I do hereby release CP from any responsibility due to loss or damage of any valuables that I, or anyone accompanying me, may bring to a CP medical practice, office or facility.

TREATMENT FOR BEHAVIORAL HEALTH: The purpose of meeting with a Behavioral Health Manager is to get help with problems in your life that are bothering you or that are keeping you from being successful in important areas of your life.

It is important to take care of both your mind and your body. Your BHM will ask questions, listen to you and suggest a plan for improving these problems. It is important that you feel comfortable talking to your BHM about the issues that are bothering you. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust. Privacy, also called confidentiality, is an important and necessary part of good treatment.

EXPECTATIONS OF CONFIDENTIALITY (BEHAVIORAL HEALTH): As a general rule, BHMs will keep the information you share with them in sessions confidential. There are, however, important exceptions to this rule that are important for you to understand before you share personal information. In some situations, BHMs are required by law or by the guidelines of our profession to disclose information whether or not you have given your permission. Please see the list of some of these situations below.

•In your doctor’s office, we work together as a team. Therefore, your information may be shared with your provider and/or with our psychiatric consultant, for treatment purposes.

•You tell your BHM that you plan to cause serious harm or death to yourself, and your BHM believes you have the intent and ability to carry out this threat in the very near future.

•You tell your BHM that you plan to cause serious harm or death to someone else who can be identified, and your BHM believes you have the intent and ability to carry out this threat in the very near future.

• You tell your BHM that you are being abused physically, sexually or emotionally, or that you have been abused in the past. In this
situation, your BHM is required by law to report the abuse to the Department of Child Safety and possibly the police.

• Additional circumstances under which confidentiality is not maintained include supervision and consultation. Clinical Supervisor:
Jeffrey Ainsa, LCSW

• All other discussions will occur only when a Release of Information Form has been completed, identifying who the information is to be
released to and what specific information is to be released.

RELATIONSHIP WITH THE BEHAVIORAL HEALTH MANAGER: The relationship between you and your BHM will be limited to the relationship of BHM and patient only. There are important differences between treatment and friendship. Friends may see your position
only from their personal viewpoints and experiences. Friends may want to find quick and easy solutions.

A BHM offers you choices and helps you consider what is best for you. BHMs are required to keep the identity of their patient confidential. Therefore, your BHM may not acknowledge you when you meet in a public place, and must decline to attend your family’s gatherings if invited. Lastly, when treatment is completed, your BHM will not be able to be a friend to you like your other friends. In sum, your BHM’s duty is to care for you and other patients, but only in the professional role of BHM. Your BHM is not permitted to give or to receive gifts from patients except tokens with personal meaning to the treatment process.

TREATMENT RISKS AND BENEFITS (BEHAVIORAL HEALTH): Approaches that are commonly utilized by your BHM include cognitive behavioral therapy (CBT), and dialectical behavior therapy (DBT). At times, and if deemed clinically appropriate and necessary, your BHM may administer a variety of screening and assessment tools. Your signature indicates your consent to allow your BHM to administer these instruments as clinically indicated. Treatment goals are identified and discussed with you after the initial meeting, and as a patient it is your responsibility to participate in working toward the goals set.

Emotional risks involved in treatment include disclosing personal feelings, talking about life experiences which may at times be painful or upsetting, asking for help and assistance, expressing emotions such as affection, anger, fear, and sadness, receiving emotional support, and receiving positive and constructive feedback.

In addition, there is the potential for therapeutic services rendered to result in no benefit to the patient. I, or my legal representative, certify that I have read this document, that it has been fully explained to me and that I understand its contents, and hereby agree to all terms and conditions set forth above and acknowledge the
receipt of a copy if requested.

THIS NOTICE DESCRIBES HOW ClearPath Family Healthcare (CP) MIGHT USE AND DISCLOSE INFORMATION ABOUT YOU AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Please Review Carefully!

At ClearPath Family Healthcare (CP), we are committed to treating and using Protected Health Information about you responsibly. This Notice of Privacy Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your individual rights as they relate to your Protected Health Information. This Notice is effective Jan 1, 2021 and applies to all Protected Health Information as defined by federal regulations.

Understanding Your Health Record/Information
Each time you visit CP, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your chart or medical record, 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;

·      Tool in educating health professionals;

·      Source of data for medical research;

·      Source of information for public health officials charged with improving the health of this state and the nation;

·      Source of data for our planning and marketing; and

·      Tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

 

Your Health Information Rights
Although your health record is the physical property of CP, the information belongs to you. You have the following rights:

·      Right to a Paper Copy of this Notice. You may ask us to give you a copy of this Notice at any time.

·      Right to Inspect and Copy. You have the right to inspect and copy Protected Health Information that may be used to make decisions about your care. We may deny your request to inspect and copy in certain very limited circumstances.

·      Right to Amend. You may request that we amend the Protected Health Information CP has about you if you feel it is incorrect or incomplete. You may request an amendment for as long as the information is kept by the practice.

·      Right to an Accounting of Disclosures. You may request an “accounting of disclosures.” This is a list of the disclosures CP has made of Protected Health Information about you.

·      Right to Request Confidential Communications. You may request that we communicate with you about medical matters in a certain way or at a certain location.

·      Right to Request Restrictions. You have the right to request a restriction or limitation on the Protected Health Information we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the Protected Health Information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

·      Right to Revoke Your Authorization. You may revoke your authorization to use or disclose Protected Health Information except to the extent that the action has already been taken.

·      Right to Opt out. We may use or disclose your Protected Health Information, as necessary, in order to contact you for fundraising activities. You have the right to opt out of receiving fundraising communications.

·      Right to Receive Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

·      Out-of-Pocket Payments. If you paid out-of- in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

 

CP’s Responsibilities
•          Maintain the privacy of your health information.

•          Provide you with this 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.

•          Notify you if we are unable to agree to a requested restriction.

•          Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our policy and to make the new provisions effective for all protected health information we maintain. You are entitled to a paper copy of our Notice of Privacy Practices at any time at your request.

We will not use or disclose your Protected Health Information without your authorization, except as described in this Notice. We will also discontinue using or disclosing your Protected Health Information after we have received a written revocation of your authorization.

For More Information or to Report a Problem If you have questions, would like additional information, or believe your privacy rights have been violated, you can contact the: ClearPath Family Healthcare LTD Attn: Shaun Romero 7725 N. 43rd Ave Suite 720Phoenix, AZ 85051 623-207-5465

 

Examples of Disclosures and Uses of Your Protected Health Information Treatment. We may use Protected Health Information about you to provide you with medical treatment or services. We may disclose Protected Health Information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you at the practice or the hospital. For example, we may disclose Protected Health Information about you to people outside the practice who may be involved in your medical care, such as family members, clergy, or other persons who are part of your care. Payment. We may use and disclose Protected Health Information about you so that the treatment and services you receive at the practice may be billed to and payment may be collected from you, an insurance company, or a third party.

 

For example, we may disclose your record to an insurance company, so that we can get paid for treating you; we may disclose your account information to our third-party business associates for payment(s). Healthcare Operations. We may use and Protected Health Information about you for healthcare operations. These uses and disclosures are necessary to run the practice and provide your healthcare. We also may disclose information to doctors, nurses, technicians, medical students, and other practice personnel for review and learning purposes. For example, we may review your record to assist our quality improvement efforts.

 

Business Associates. There are some services provided in our organization through contacts with business associates. An example is certain tests performed by outside laboratories. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associates to appropriately safeguard your information. Appointment Reminders/Treatment Alternatives/Health-Related Benefits and Services. We may use and disclose Protected Health Information to contact you to remind you that you have an appointment for medical care, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you. 

 

Research .We may use and disclose your Protected Health Information for research purposes, but we will only do that if the research has been specially approved by an authorized institutional review board or a privacy

board that has reviewed the research proposal and has set up protocols to ensure the privacy of your Protected Health Information.

As Required by Law. We will disclose Protected Health Information about you when required to do so by international, federal, state, or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose Protected Health Information when necessary to prevent a serious threat to your health or safety or to the health or safety of others. But we will only disclose the information to someone who may be able to help prevent the threat.

 

Workers’ Compensation. We may use or disclose Protected Health Information for workers’ compensation or similar programs that provide benefits for work-related injuries or illness.

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

Law enforcement: We may disclose Protected Health Information for law enforcement purposes as required by law or in response to a valid subpoena.

 

Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

Abuse, Neglect, or Domestic Violence. We may disclose Protected Health Information to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence and the patient agrees or if we are required or authorized by law to make that disclosure.

Military and Veterans. If you are a member of the armed forces, we may disclose Protected Health Information as required by military command authorities. We also may disclose Protected Health Information to the appropriate foreign military authority if you are a member of a foreign military.