Miscellaneous Consents and Other Policies
1. Provider Communications and Access. The AFP Patient Portal provided to you provides staff and provider messaging, appointment requests, and bill payment functions, as well as others. Otherwise, access to our providers outside of appointments is limited.
These items, among others, require an appointment with your provider:
- Require a new or modified prescription,
- Have a new or changing condition, illness or symptom,
- Require a referral or medical order,
- Have documents that require signature or review,
- To review completed orders or test results.
- Any type of “consult” with your provider.
2. Test Results. Test results including, CTs, Xrays, Blood Tests, and others, fall into two categories: Medically Concerning or Medically Unconcerning. Test results may be slightly abnormal, yet still be unconcerning as related to your care or condition. Most test results will be available to you on your Patient Portal. You will be notified by email when information is received from us on your Portal. If your results are Medically Concerning, and if a follow up appointment isn’t already scheduled, we will contact you to schedule an appointment to review your results with you.
3. Medication Refill Requests. Please contact your pharmacy first to send us an electronic refill request.
4. “Good Fit” Policy. As a private practice, we reserve the right to decline entrance into our practice, or to continue to manage patients that are inappropriate with staff, providers, or the business in general including Internet and Social Media. Inappropriate communication, behavior, or actions with staff are never tolerated, and will result in termination from our practice panel.
5. Home Care. We are unable to provide, or continue to provide, care for patients that become home-bound for any reason. Once the transition to home-bound care begins, we will assist in securing placement with an appropriate group or provider.
6. Treatment Non-Compliance. If there is a failure to follow treatment plans, diagnostic testing, or referrals to outside providers for conditions that are either not fully diagnosed and could pose a danger to the health of a patient, or are known to be dangerous to the patients health, due to willful non-compliance, that patient will be discharged from our practice.
7. Controlled Substance Prescribing. We no longer provide monthly (chronic use) controlled substance prescriptions for opioids, benzodiazepine (Ativan, Xanax, etc), or hypnotic (Ambien, Lunesta, etc) medications. Some of these drugs may be provided for acute issues on a short-term basis. If you are a new patient requiring these medications, a referral to an outside prescriber (Pain, Psychiatry, etc.) can be provided.
8. Cannabis Cards. We provide cannabis cards for qualifying conditions (see the NM DOH Cannabis Application for a list of these conditions). For patients currently in cancer treatment, a Cannabis Application can be completed for free, otherwise there is a $100 charge for a new card application, and a $75 charge for application renewals. Documentation of your condition is required, and for psychiatric complaints, a letter from a NM Licensed Psychiatric provider confirming the diagnosis is required.
Consent to Treat
I consent to evaluation, diagnostic procedures, testing, and treatment as directed my Adler Family Practice Provider or his/her designee. I understand that I may request and receive information on the specific affiliation(s) of any particular healthcare provider I encounter during my care. I understand that this Consent to Treat will be valid for each visit I make to Adler Family Practice until revoked by me in writing.
Consent to Release Information
I acknowledge that Adler Family Practice may release my protected health information as necessary for treatment, payment and health care operations and acknowledge that Adlers Notice of Privacy Practice provides information on how my protected health information may be used and/or disclosed for these purposes. I understand that protected health information pertains to my diagnosis and/or treatment, and includes, but is not limited to, information related to my health history, diagnosis, treatment, prognosis, mental illness (excluding psychotherapy notes), use of alcohol or drugs, prescriptions and laboratory test results, including HIV or the diagnosis of AIDS. I understand that use or disclosure of my protected health information may be necessary before my insurer will pay for the cost of my medical treatment and that if I refuse to consent to this disclosure I may be required to pay the entire cost of medical care provided by Adler Family Practice. I acknowledge and consent to allow Adler Family Practice to use health information exchange systems to electronically transmit, receive and/or access my medical information, which may include, but is not limited to, treatments, prescriptions, labs, medical and prescription history and other protected health information. I may “opt out” and not have my protected health information disclosed through health information exchange systems by providing the signed Adler “opt-out” form to the practice location where I receive treatment.
Consent to Photograph/Digital Imaging
I consent to photographs/digital images for treatment, and to verify identity for payment purposes. I understand that the Adler Family Practice will retain the ownership rights to these photographs/digital images, but that I will be allowed access to view them or obtain copies.