New Patient Agreement Form

Medication Agreement

The purpose of this agreement is to prevent misunderstandings about medications and the importance of following your prescribed treatment plan. The Advaita Collective has a “Zero Tolerance Policy” when treatment plans are given to patients and they are not fulfilled.

Please sign below in acknowledgment and in agreement of the following statements. If you have any questions, please bring them up with your provider.

 

• I understand that this agreement is essential to the trust and confidence necessary in a doctor/patient relationship and that my doctor undertakes to treat me based on this agreement.
• I understand that if I break this Agreement, my doctor will stop prescribing medications and I will have to find another provider.
• I will communicate fully with my doctor about the character and intensity of my symptoms, the effects on my daily life, and how well the medicine is working.
• I will not use any illegal substances, including marijuana, cocaine, etc., nor will I misuse or self prescribe/medicate with legal controlled substances. Use of alcohol will be limited to a time when I am not driving, operating machinery and will be infrequent.
• I will not share my medication with anyone.
• I will not attempt to obtain any controlled stimulants or controlled anti-anxiety medications from any other doctor without consent of my provider at AIM. If I am found to do so, I understand I will be dismissed from the practice.
• I will safeguard my pain medication from loss or theft. I understand lost or stolen medications will not be replaced.
• I agree that I will submit to a blood or urine test if requested by my doctor to determine my
  compliance with my program of controlled medications.
• I agree that I will use my medicine at a rate no greater than the prescribed rate and that use
  of my medicine at a greater rate will result in my being without medication for a period of time.
• I authorize my provider and my pharmacy to cooperate fully with any city, state, or federal law enforcement agency, including this state's Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my medications.
• I authorize my doctor to provide a copy of this agreement to my pharmacy, primary care physician and local emergency room.
• I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations.

Appointment Policy

The keeping of regular appointments is crucial to successful treatment. As the schedule permits, we will work out a most convenient time for you for these appointments. The scheduling of an appointment constitutes an agreement to pay for the professional time reserved exclusively for you. It is extremely important that you show up for your scheduled appointment with our office. Please read the below statements carefully.

• I understand that not showing up for an appointment is a missed opportunity for my health conditions to be monitored and or managed.
• I understand that not showing up for an appointment is a missed opportunity for another patient with healthcare needs who could have been seen during that time.
• I understand that the Advaita Collective's policy is to charge for missed appointments or appointments canceled with less than 24 hours notice at the rate of $100.00. I understand that I will be billed directly for this time.
• I understand that I need to arrive at least 15 minutes prior to my scheduled appointment time. My appointment time is the time when my provider sees me in the room, so I understand that the extra time is to allow me to check in with the front desk.
• I understand that if I arrive 10 minutes AFTER my appointment time, there is a chance the Advaita Collective will need to reschedule my appointment to ensure my provider has the proper time with me and does not get behind.

Payment of Fees

I certify that I (or my dependent) have insurance coverage and assign directly to Advaita Health Ventures, LLC, DBA the Advaita Collective and its affiliated companies, Advaita Integrated Medicine, PLLC and Green Hill Recovery, LLC, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether paid by insurance. I also understand that I am responsible for obtaining any initial authorizations required by my insurance carrier for each separate provider that I see. I hereby authorize the doctor/therapist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

The Advaita Collective requires patients to maintain an active credit, debit, or HSA card on file for the purposes of billing. This information will be maintained along with your demographic information in our secure records system. If you need to change your method of payment, please let office staff or your provider know at the time of your appointment.

I understand that the Advaita Collective's policy is to charge for missed appointments or appointments canceled with less than 24 hours notice at the rate of $100.00. I understand that I will be billed directly for this time.

Payment of any unpaid balance on an account must be received in full before the close of the month. Payments are non-refundable. You will be charged a $25 service charge for all returned checks. Unpaid balances older than 90 days will be subject to collections proceedings. This process includes the addition of a thirty-three and one-third (33 1/3) percent attorney fee to your unpaid balance. Service may be interrupted until payment is made.

Reports, Consultations, & Clerical Matters

Any reports or professional consultations involving time beyond that of the regular scheduled session will be billed at a pro-rated charge for the professional time involved. We will charge for telephone, email and/or communication consultations with your provider, which are longer than five minutes, at the usual and customary rate should your provider deem it appropriate. Psychological Testing results may not be released until the testing bill is paid in full.

Release of Information

The patient agrees that his/her clinician may share information with other professional staff at Advaita Health Ventures, LLC, DBA the Advaita Collective and its affiliated companies, Advaita Integrated Medicine, PLLC and Green Hill Recovery, LLC, with regard to his/her case in order to better provide quality treatment. This information will be kept strictly confidential and remain in the confines of the Advaita Collective only.

Telehealth Consent

I understand that telehealth, teletherapy, and telepschyiatry involve the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to receiving health care services to me via telehealth over secure video conferencing platform and other communication and electronic tools. I understand that the laws that protect privacy and the confidentiality of my medical information also apply to telehealth. I understand that my provider may decide that telehealth is not appropriate for me, and may require me to be seen in person.

Consent for Treatment

The undersigned patient or responsible party (parent, legal guardian, or conservator) consents to, and authorizes, services by Advaita Health Ventures, LLC, DBA the Advaita Collective and its affiliated companies, Advaita Integrated Medicine, PLLC and Green Hill Recovery, LLC,). These services may include medication management, laboratory tests, diagnostic procedures, and other appropriate therapies. He/She/They understand that he/she/they have the right to be informed of and participate in the selection of treatment modalities; if requested, is entitled to a copy of this Consent; and has the right to withdraw this consent at any time. He/she/they understand that if signed consent is not given, the Advaita Collective cannot provide services to the patient.

Authorization to Leave Messages, Receive Emails, & Receive Texts

I hereby authorize that phone messages, emails, and/or text messages are allowed to be left at the above email address / phone number(s) regarding my prescriptions, appointments, and care from the Advaita Health Ventures, LLC, DBA the Advaita Collective, and its affiliated companies, Advaita Integrated Medicine, PLLC and Green Hill Recovery, LLC. I understand that my electronic signature is the legal equivalent of my manual/handwritten signature on this document.

Notice of Privacy Practices

The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information. As required by “HIPAA” we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes:

• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company
  for payment.
• Healthcare operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer services. An example would
  be an internal quality assessment review.
• We may also create and distribute de-identified health information by removing all references to individually identifiable information.
• We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken
actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a
written request to the Privacy Officer:

• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friend, or any other person identified by you.
  We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
• The right to inspect and copy your protected health information.
• The right to amend your protected health information.
• The right to receive an accounting of disclosures of protected health information.
• The right to obtain a paper copy of this notice from us upon request.
• We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that our privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint. Please contact us for more information at the address listed at the bottom of the page.

For more information about HIPPA or to file a complaint:
The U.S. Dept. of Health & Human Services Office of Civil Right
200 Independence Avenue, S.W.
Washington, D.C. 20201

Patient Acknowledgment
I understand that the patient’s health information is private and confidential. I understand that the Advaita Collective works very hard to protect the patient’s privacy and preserve the confidentiality of the patient’s personal health information. I understand that Advaita Integrated Medicine may use and disclose the patient’s personal health information to help provide healthcare to the patient, to handle billing and payment, and to take care of other health care operations. (In general, there are no other uses and disclosures of this information unless I permit it. I understand that sometimes the law may require the release of this information without my permission. These situations are very unusual. One example would be if a patient threatened to hurt someone.)

The Advaita Collective has a detailed document called the “Notice of Privacy Practices”. It contains more information about the policies and practices protecting the patient’s privacy and is attached to this Acknowledgment. I understand that I have the right to read the “Notice of Privacy Practices”. If I ask, Advaita Integrated Medicine will provide me with the most current “Notice of Privacy Practices”. Within the Notice of Privacy, Practices is contained a complete description of my privacy/confidentiality rights. These rights include but aren’t limited to, access to my medical records: restrictions on certain uses; receiving an accounting of disclosures as required by law; and requesting communication be by specified methods of communications or alternative locations. Advaita Integrated Medicine has established procedures that help them meet their obligations to patients. Their procedures may include other signature requirements, written acknowledgments information, charges for copies and non-routine information needs, etc. I will assist Advaita Integrated Medicine by following these procedures if I choose to exercise any of my rights described in the “Notice of Privacy Practices”.