In accordance with the Health Insurance Portability and Accountability Act of 1996, as of April 14, 2003 all health care providers are required to provide their patients with a "Notice of Privacy Practice' statement.
NOTICE OF HIPAA PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Journey Healthcare is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our clients with notice of our legal duties and privacy practices with respect to your protected health information
Disclosure of Your Health Care Information
We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. For example, on occasion, it may be necessary to seek consultation regarding your condition from other health care professionals associated with Journey Healthcare.
We may disclose your health information to your insurance provider for the purpose of payment of health care operations. For example, as a courtesy to our clients, we will submit an itemized billing statement to you and/or your insurance carrier for the purpose of payment to Journey Healthcare for health care services rendered. The billing statement contains medical information, including diagnosis, date of condition and codes that describe the health care services rendered.
We may disclose your health information as necessary to comply with State Workers' Compensation Laws.
We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or your death.
As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications and reporting disease or infection exposure.
Juridical and Administrative Proceedings
We may disclose your health information in the course of any administrative or judicial proceeding.
We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a good cause court order or subpoena and other law enforcement purposes.
We may disclose your health information to coroners or medical examiners.
We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.
We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.
It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.
Specialized Government Agencies
We may disclose your health information for military, national security, prisoner or government benefits purposes.
We may contact you for purposes of reminding you that you have an appointment for treatment at our office.
Change of Ownership
In the event that Journey Healthcare is sold or merged with another organization, your health information/record will become the property of the new owner.
Your Health Information Rights
You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that Journey Healthcare is not required to agree to the restriction that you request. You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication of delivery, upon your request. You have the right to inspect and copy your health information. You have the right to request that Journey Healthcare amend your protected health information. Please be advised, however, that Journey Healthcare is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial. You have a right to receive an accounting of disclosures of your protected health information made by Journey Healthcare. You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
Changes to this Notice of Privacy Practices
Journey Healthcare reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Journey Healthcare is required by law to comply with this Notice.
Journey Healthcare is required by law to maintain the privacy of your health information and to provide you with notice of its' legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact the HIPAA Privacy Practice Officer by calling our office at the number listed in the Client Handbook.
Releases of information permitted by HIPAA regulations which are prohibited by the Federal and State Confidentiality Laws for substance abuse treatment, continue to be prohibited and will require the client's written consent.
Complaints about your Privacy rights or how Journey Healthcare has handled your health information should be directed to the HIPAA Privacy Practice Officer at Journey Healthcare. If s/he is not available, you may make an appointment for a personal conference in person or by telephone within two working days. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:
DHHSOffice of Civil Rights200 Independence Avenue, S.W.Room 509F HHH BuildingWashington, D.C. 20201
I have read the Privacy Notice and understand my rights contained in this notice.
By way of my signature, I provide Journey Healthcare with my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment and healthcare operations as described in the Privacy Notice.
Federal and State Laws and regulations protect the confidentiality of client records maintained by Journey Healthcare. Journey will not disclose any information identifying a client as a recipient of treatment services unless:
As a client of Journey, you are entitled to the following:
This request will be presented to the Program Manager, along with your record to the Program Manager. All such requests will be honored within 7 days. You may request a correction or removal, if the information is inaccurate, irrelevant, or incomplete. Appeal related to the retention or destruction of record contents are to be mediated by the Program Manager. You may submit rebuttal data or a memorandum to your record.
Consent to Treatment
During your treatment at Journey HEalthcare, you will be expected to adhere to the following:
Abusive behaviors include (but is not limited to):
My initials indicate my acknowledgement of the aforementioned 'No Show' policy and associated rates: blank*
Client Medication Refills
Before contacting the office, please call the pharmacy directly to ensure that you do not have any additional refills on file. Please note we do not respond to pharmacy generated automated refill requests. If you require additional medication before your next appointment, please contact the office as soon as possible. It may take up to five business days to refill your medication and you must have a follow up appointment scheduled: please do not expect that the medication will be filled on the same day as the request.
Certain medications cannot be prescribed electronically or via telephone and must be provided through a scheduled visit at Journey Healthcare. Prescriptions will not be mailed to you for any reason. Please ensure that you have an adequate supply of medication to last until your next scheduled appointment.
If you or your child are prescribed a controlled prescription including stimulants or benzodiazepines, the medication must be stored securely and taken as directed. If appointments are canceled/changed refill requests may not be honored until you are seen in the office. Misuse or sale/distribution of medication will result in discontinuation of treatment or ternination of care.
Refill requests if made subsequent to a missed or cancelled/changed appointment or if you have repeated requests for refills, you will be charged a fee of $50 at the time the refill is processed.
Payment Policy, Fee Schedule & Credit Card Authorization
Fees must be paid directly to the receptionist prior to your designated appointment. If payment is not received, then the visit will be re-scheduled for a later date. Payment must be received before you are seen by the provider. If you do not pay, you will be re-scheduled and you will not receive a prescription.
Journey Healthcare participates in some commercial insurance plans. It is your responsibility to alert us of any changes to your insurance. All insurance related copayments, coinsurance and deductibles are due at time of service. Should yourinsurance not cover a desired service offered by Journey Healthcare it is your responsibility to cover any service incurred. We accept all major forms of credit cards, cash and certified checks.
The fee schedule is posted in the main lobby of the facility and in your initial client handbook. If you need an additional copy you may request one and it will be given to you.
If you need an additional copy, you may request one. I understand the full payment is required at the time of service by either cash or credit card.
I also understanding that the financial responsibility for services is mine, and that I must provide any information regarding active insurance to Journey Healthcare.
I understand that if the credit card charge is denied, I will be billed separately for the appointments. I understand that I must pay for any outstanding balance in full before receiving further services.
I agree to call and notify the receptionist in advance of my next scheduled appointment if my address, phone number, or responsible party has changed.
I agree to provide Journey Healthcare with an active credit card to bill during utilization of telehealth servicesor for any incurred balance.
I agree to keep an active credit card on file at all times. I agree to call and notify the receptionist if my credit card expires and will provide a current one prior to my next service.
The undersigned authorizes Journey Healthcare to charge account balances to the provided credit card for Services Rendered at Journey Healthcare.
Should any balance be open on your account at time of discharge or discontinued treatment the remaining balance shall be run in full. By signing below, I acknowledge and consent to the use of your credit card without signature on the charge slip, that this agreement will serve as an original and this credit card authorization.
Acknowledgement of Receipt of Client Handbook
I acknowledge that I have received a copy of the Journey Healthcare Client Handbook at the time of my admission and that I have been informed that I am free to ask questions about it at any point throughout my treatment. Fees were also discussed with me at the time of my intake.
Informed Consent Telemedicine Services
I understand that it is my obligation to notify Journey Healthcare of my location at the beginning of each treatment session. If for some reason, I change locations during the session, it is my obligation to notify Journey Healthcare of the change in location.
I understand that it is my obligation to notify Journey Healthcare of any other persons in the location, either on or off camera and who can hear or see my sessions. I understand that I am responsible to ensure privacy at my location. I will notify Journey Healthcare at the outset of each session and am aware that confidential information may be discussed.
I agree that I will not record either through audio or video any of the sessions.
I understand there are potential risks to using telehealth technology, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand some of these technological challenges include issues with software, hardware, and internet connection which may result in interruption.
I am aware that alternative care options including in person visits are available for any services I receive.
I have been trained on how to use telehealth technology by Journey Healthcare.
Telehealth is NOT an emergency service. In the event of an emergency, I will use a phone to call 911.
To maintain confidentiality, I will not share my telehealth appointment link or information with anyone not authorized to attend the session.
I understand that either I or Journey Healthcare can discontinue the telehealth services if those services do not appear to benefit me therapeutically or for other reasons which will be explained to me. I have read and understand this consent to treatment and the associated telehealth policies. By providing my signature I am acknowledging my informed consent to engage in Telehealth Virtual care services.
Emergency and Psychiatric Consent
I consent to allow Journey to procure for me in the event of a medical or psychiatric emergency and release Journey from all liability related to any injury which may occur during my treatment at this facility.
This consent is subject to my revocation at any time. It will expire at the conclusion of my treatment stay. My signature indicates that I have been provided with and understand the above information regarding my rights, responsibilities and treatment.
I First Name Last Name Consent for the release and authorization the disclosure and use of my protected health information by Journey Healthcare, in accordance with federal and/or state law, whichever is more protective of the client's confidentiality, by written copies, facsimile or verbal communication to:
I also understand:
I understand that I may revoke all or part of this authorization verbally or in writing.Please contact the office if you wish to revoke this consent.
This Consent/Authorization complies with the Privacy Regulations contained within Federal Register Vol. 65, Part II, Part 164; SubPart E 164.508.
PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal regulations prohibit you from making any further disclosures of this information except with the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general release of medical or other information is NOT sufficient for this purpose.