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.

    We are required by law to maintain the privacy of your health information in accordance with federal and state law. In particular, we protect the privacy and security of your substance use disorder patient records in accordance with 42 U.S.C. § 290dd–2 and 42 C.F.R. Part 2, the Confidentiality of Substance Use Disorder Patient Records (“Part 2”), in addition to HIPAA and applicable state law. This Notice of Privacy Practices (“Notice”) outlines our legal duties and privacy practices with respect to health information. We are required by law to provide you with a copy of this Notice and to notify you following a breach of your unsecured health information.

    We will abide by the terms of the Notice. We reserve the right to make changes to this Notice as permitted by law. We reserve the right to make the new Notice provisions effective for all health information we currently maintain, as well as any health information we receive in the future. If we make material or important changes to our privacy practices, we will promptly revise our Notice. Each version of the Notice will have an effective date listed on the first page. If we change this Notice, you can access the revised Notice on our website (www.addictionology.conter).

    You have the right to file a complaint if you believe your privacy rights have been violated. If you would like to file a complaint about our privacy practices, you can do so by sending a letter outlining your concerns to: www.addictionology.center, Attn: Privacy Officer, 5203 Chippewa, Suite 301; St. Louis, MO 63109, or by contacting our Privacy Officer by telephone at 314-481-5000. You also have the right to complain to the Secretary of the United States Department of Health and Human Services, the United States Attorney for the judicial district in which the violation occurs, and the Substance Abuse and Mental Health Services Administration (“SAMHSA”) office responsible for opioid treatment program oversight. You will not be penalized or otherwise retaliated against for filing a complaint.

    USES AND DISCLOSURES OF YOUR HEALTH INFORMATION:

    We will obtain your written authorization to use and disclose your health information unless we are permitted to use or disclose your information without your authorization under applicable law. The following categories describe the ways that we may use and disclose your health information without your written authorization under Part 2. To the extent applicable state law is even more restrictive than Part 2 on how we use and disclose any of your health information, we comply with more restrictive state law.

    Within Our Organization, personnel who have a need for your information in connection with their duties that arise out of the provision of diagnosis, treatment, or referral for treatment may use and share your information.

    Emergency Treatment: In the event of a bona fide medical emergency in which your prior authorization cannot be obtained, we may disclose your identifying information to medical personnel. We will obtain your authorization prior to disclosing your information for non-emergent treatment.

    Business Associates/Qualified Service Organizations. We may disclose your information to third party “business associates” and “qualified service organizations” that perform various services on our behalf, such as transcription, billing, and collection services, and who agree to protect the privacy of your health information.

    Audits: We may disclose your health information to entities who are legally permitted to perform audits of our facilities. Those entities are required to maintain the privacy of your information.

    Legal Proceedings We may disclose your health information pursuant to court orders that meet the requirements of applicable law.

    Reporting Crimes on Our Premises or Against Our Personnel. We may disclose a patient’s commission (or threatened commission) of a crime on our premises or against our personnel to a law enforcement agency or official. We are permitted to disclose information regarding the circumstances of such incident, including the suspect’s name, address, last known whereabouts, and status as a patient in our program.

    Reporting Child Abuse or Neglect: We may report incidents of suspected child abuse and neglect to the appropriate state or local authorities.

    Deceased Persons: We may disclose information relating to the cause of death of a patient under laws requiring the collection of death or other vital statistics or permitting inquiry into the cause of death.

    Research: Under certain circumstances, we may disclose your health information to researchers who are conducting a specific research project. Your identifying information will never be published without your written authorization.

    FDA Reporting: We may disclose patient identifying information to medical personnel of the Food and Drug Administration (FDA) who assert a reason to believe that the health of any individual may be threatened by an error in the manufacture, labeling, or sale of a product under FDA jurisdiction, and that the information will be used for the exclusive purpose of notifying patients or their physicians of potential dangers.

    OTHER USES AND DISCLOSURES:

    Use or disclosure of your health information for any purpose other than those listed above requires your written authorization. Some examples include:

    • Psychotherapy Notes: We will not use and disclose your psychotherapy notes without your written authorization except as otherwise permitted by law.
    • Release of Your Presence in Our Facility: We will not disclose your presence in treatment to individuals who may contact us unless you have provided your written authorization permitting the release.
    • Marketing: We will not use or disclose your health information for marketing purposes without your written authorization except as otherwise permitted by law.
    • Sale of Your Health Information: We will not sell your health information without your written authorization except as otherwise permitted by law.

    If you change your mind after authorizing a use or disclosure of your health information, you may withdraw your permission by revoking the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of your health information that occurred before you notified us of your decision, or any actions that we have taken based upon your authorization.


    Your rights regarding your health information:

    This section describes your rights regarding the health information we maintain about you. All requests or communications to exercise your rights discussed below must be submitted in writing.

    Right to Inspect and Copy. You have the right to inspect and receive a copy of your health information, excluding your psychotherapy notes. We may charge you a fee as authorized by law to meet your request. You may request access to your health information in a certain electronic form and format, if readily producible, or, if not readily producible, in a mutually agreeable electronic form and format. Further, you may request in writing that we transmit such a copy to any person or entity you designate. Your written, signed request must clearly identify such designated person or entity and where you would like us to send the copy. We may deny your request to inspect and copy in limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed by a licensed health care professional chosen by us. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

    Right to Request Confidential Communications. You have the right to request that we communicate your health information to you in a certain manner or at a certain location. For example, you may wish to receive information through a written letter sent to a private address. We will grant reasonable requests. We will not ask you the reason for your request.

    Right to Amend. You have a right to request that we amend or correct your health information that you believe is incorrect or incomplete. For example, if your date of birth is incorrect, you may request that the information be corrected. To request a correction or amendment to your health information, you must make your request in writing and provide a reason for your request. You have the right to request an amendment for as long as the information is kept by or for us. Under certain circumstances we may deny your request. If your request is denied, we will provide you with information about our denial and how you can file a written statement of disagreement with us that will become part of your medical record.

    Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures we make of your health information. Please note that certain disclosures need not be included in the accounting we provide to you, including most disclosures we make pursuant to your authorization. Your request must state a time period which may not go back further than six years. You will not be charged for this accounting, unless you request more than one accounting per year, in which case we may charge you a reasonable cost-based fee for providing the additional accounting(s). We will notify you of the costs involved and give you an opportunity to withdraw or modify your request before any costs have been incurred.

    Right to Request Restrictions. HIPAA provides that you have the right to request restrictions on how your health information is used or disclosed for treatment, payment, or health care operations activities but that we are not required to agree to your requested restriction, unless that restriction is regarding disclosure of health information to your health insurance company and: (1) the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law; and (2) the health information pertains solely to a health care item or service for which you or another person (other than your health insurance company) paid for in full. Note, however, that Part 2 requires that we obtain your written authorization for most disclosures, except as expressly outlined above.

    Right to a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice at any time, even if you previously agreed to receive this Notice electronically. A copy of this Notice can be obtained at any time from our website at www.addictionology.center


    Telehealth Informed Consent

    Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care. This “Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of using a telehealth platform.

    Services Provided:

    Telehealth services offered by www.addictionology.center (“Group”), and the Group’s engaged providers (our “Providers” or your “Provider”) may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services”). Your Provider will be licensed in the state where you are located at the time of your consultation, or otherwise meet a professional licensure exception under applicable state law, and will establish a provider-patient relationship in accordance with the laws and rules in the applicable state.

    www.addictionology.center does not provide the Services; it performs administrative, payment, and other supportive activities for Group and our Providers.

    Electronic Transmissions:

    The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:

    Appointment scheduling:

    Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and your Provider via:

    • asynchronous communications
    • two-way interactive audio in combination with store-and-forward communications; and/or
    • two-way interactive audio and video interaction
    • Treatment recommendations by your Provider based upon such review and exchange of clinical information

    Delivery of a consultation report with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant
    Prescription refill reminders (if applicable)
    Other electronic transmissions for the purpose of rendering clinical care to you.

    Expected Benefits:

    Improved access to care by enabling you to remain in your preferred location while your Provider consults with you. Our telehealth services are available 8 hours a day, 5 days a week.

    Convenient access to follow-up care. If you need to receive non-emergent follow-up care related to your treatment, please contact your Provider by sending a message via the Spruce app.

    More efficient care evaluation and management. You can expect a response within 1 hour during the business day by a trained health coach for any administrative and/or care coordination issues. Your provider will typically respond to any non-emergent messages within 1 business day during the week or during the next business days over weekends and holidays.

    Service Limitations:

    The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.

    Our providers do not address medical emergencies. If you believe you are experiencing a medical emergency, You should dial 9-1-1 and/or go to the nearest emergency room. please do not attempt to contact www.addictionology.center group, GROUP, or your Provider. After receiving emergency healthcare treatment, you should visit your local primary care PROVIDER.

    Our Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not.

    Security Measures:

    The electronic communication systems we use 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 and to ensure its integrity against intentional or unintentional corruption. All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and AccountabilityAct of 1996 (“HIPAA”).

    Possible Risks:

    • Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or provider availability.
    • In the event of an inability to communicate as a result of a technological or equipment failure, please contact the Group
    • In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a re-scheduled telehealth consult or an in-person meeting with your local primary care doctor
    • In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

    Patient Acknowledgments:

    I further acknowledge and understand the following:

    1. Prior to the telehealth visit, I have been given an opportunity to select a provider as appropriate, including a review of the provider’s credentials, or I have elected to visit with the next available provider from Group, and have been given my Provider’s credentials.
    2. If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and my Provider is not able to connect me directly to any local emergency services.
    3. I may elect to seek services from a medical group with in-person clinics as an alternative to receiving telehealth services.
    4. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment.
    5. Federal and state law requires health care providers to protect the privacy and the security of health information. I am entitled to all confidentiality protections under applicable federal and state laws. I understand all medical reports resulting from the telehealth visit are part of my medical record.
    6. Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state.
    7. Dissemination of any patient identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my affirmative consent.
    8. There is a risk of technical failures during the telehealth visit beyond the control of Group. I AGREE TO HOLD HARMLESS GROUP AND ITS EMPLOYEES, CONTRACTORS, AGENTS, DIRECTORS, MEMBERS,MANAGERS, SHAREHOLDERS, OFFICERS, REPRESENTATIVES, ASSIGNS, PARENTS,PREDECESSORS, AND SUCCESSORS for delays in evaluation or for information lost due to such technical failures.
    9. In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.
    10. Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies. If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role.
    11. My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options
    12. I have the right to request a copy of my medical records. I can request to obtain or send a copy of my medical records to my primary care or other designated health care provider by contacting Group by sending a message in the Spruce app or sending an email. A copy will be provided to me at reasonable cost of preparation, shipping and delivery.
    13. It is necessary to provide my Provider a complete, accurate, and current medical history. I understand that I can log into my “Portal” at any time to access, or review my health information.
    14. There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgement of my Provider.
    15. If my Provider issues a prescription, I have the right to select the pharmacy of my choice.
    16. There is no guarantee that I will be treated by a Group provider. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.

    www.addictionology.centerand its affiliated medical groups are committed to providing the best quality healthcare services.


    General Consent to Treatment

    You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

    This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing.

    You have the right at any time to discontinue services and/or decline any and all treatments, even if against medical advice. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your healthcare provider, we encourage you to ask questions.

    I voluntarily request a physician, and/or advanced practice clinician (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).


    Patient Acknowledgement

    Our Notice of Privacy Practices resides at www.addictionology.center. It provides information about how we may use and release protected health information about you. You have the right to review our Notice before signing this form. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy by sending us an email.

    You have the right to request that we restrict how protected health information about you is used or released for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.

    By signing this form, you consent to our use and release of protected health information about you for treatment, payment and health care operations as described in our Notice. You have the right to revoke this consent in writing, and we will honor your revocation except where we have already made releases in reliance on your prior consent.

    Notice of Potential Information Loss Due to Technological Failure

    Information transmitted through telehealth technology may be lost due to technological failure beyond the control of the Group which can result in delays in treatment or other adverse consequences. I agree to hold-harmless www.addictionology.center group and its employees, contractors, agents, directors, members, managers, shareholders, officers, representatives, assigns, parents, predecessors, and successors for consequences of information loss due to technological failure.

    Consent to Obtain Medication History

    Patient medication history is a list of prescription medicines that our practice providers, or other providers, have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history.

    The collected information is stored in the practice electronic medical record system (EHR/EMR) and becomes part of your personal medical record. Medication history is very important in helping healthcare providers treat your symptoms and/or illness properly and in avoiding potentially dangerous drug interactions.

    It is very important that you and your provider discuss all your medications in order to insure that your recorded medication history is 100% accurate. Some pharmacies do not make drug history information available, and your drug history might not include drugs purchased without using your health insurance. Also over‐the‐counter drugs, supplements, or herbal remedies that patients take on their own may not be included.

    I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers. I understand this may not be a complete history, and I agree to provide a complete account of my own medication filling and use history to my Provider.

    Assignment of Benefits

    I request and permit my insurance company or benefit plan to pay directly to www.addictionology.center Group, money due for health care services, supplies and equipment under the terms of my insurance policy or benefit plan. I understand that I may be responsible for payment in full of any amount due that is not covered or paid for by my insurance policy or benefit plan. If coverage is denied, I give my express consent to appeal to the insurance on my behalf.

    Notice of Financial Responsibility

    I have received a Financial Responsibility Agreement that describes the cost of www.addictionology.center group services, and I have reviewed and understand the contents of this agreement.

    Release of Information and Statement of Assistance

    1. I permit www.addictionology.center group, to provide my insurance company or benefit plan with any information necessary for www.addictionology.center Medical Group to receive payment for services, supplies, and equipment.
    2. I permit www.addictionology.center group, and/or its attorneys to request, on my behalf, any information related to my health insurance policy or benefit plan (including, but not limited to, proof of my insurance or benefit plan). This information may be given directly to www.addictionology.center group or its attorneys.
    3. I permit www.addictionology.center group, and/or its attorneys, to file, on behalf of themselves and on my own behalf, claims for benefits and/or appeals of any denied claims.
    4. I agree to assist www.addictionology.center group in collecting benefits that may be due or payable under my insurance policy or benefit plan for the services, supplies, and equipment provided.
    5. I agree to provide any additional information needed to process the claim for payment.
    6. I agree that www.addictionology.center group may take action in my name against my insurance company or benefit plan to receive any benefits that may be due or payable under the insurance policy or benefit plan.


    Consent to receive Protected Health Information via Email and SMS

    I hereby consent and state my preference to have my www.addictionology.center group physician and other staff at www.addictionology.center group communicate with me by email or standard SMS messaging regarding various aspects of my medical care, which may include, but shall not be limited to, test results, prescriptions, appointments, and billing.

    I understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS messaging regarding my medical care might be intercepted and read by a third party.

    Consent to Receive Texts and Emails from www.addictionology.center group and its Business Partners

    By providing your cell phone number and email address to www.addictionology.center group, you are agreeing to be contacted by or on behalf of www.addictionology.center group and our business partners identified below at the email address and the telephone number provided, including emails to your email address and text (SMS) messages to your cell phone and other wireless devices, and the use of an automatic telephone dialing system, artificial voice and prerecorded messages, to providing you with marketing and promotional materials relating to www.addictionology.center products and services, and products and services of the identified business partners. You may opt-out of receiving text (SMS) messages from www.addictionology.center or its subsidiaries at any time by replying with the word STOP from the mobile device receiving the messages. You need not provide this consent in order to purchase any products or services from www.addictionology.center. However, you acknowledge that opting out of receiving text (SMS) messages may impact your experience with the service(s) that rely on communications via text (SMS) messaging.

    Treatment Agreement

    1. I agree to be civil and never to intimidate, threaten, or verbally abuse www.addictionology.center group staff. We understand and encourage being open and showing emotion but do not tolerate hostility.
    2. I agree never to sell, share or give any of my medication to another person. We can’t allow medication that we prescribe to be used in any way other than directed by your medical provider. Sharing or selling medication is dangerous, illegal, and cause for termination of further prescriptions. We’re always happy to work with your friend or loved-one to enroll in treatment instead.
    3. I agree to take my prescribed medication exactly as directed and to notify my provider if directions are unclear or I’m unable to follow them for any reason. Never improvise or guess! We’re always here to support you, and so is your pharmacist. Do not increase or decrease your dose unless directed to do so by your provider.
    4. I agree to notify my provider anytime a new medication is prescribed by another medical provider. We must review all other medication for safety when prescribed along with the treatment that we provide, and we consider their possible effect on drug test results.
    5. I agree to provide complete and accurate answers to my provider. Your provider is a trained specialist but can’t read your mind! We make medical decisions to maximize your comfort and safety, and we rely on what you tell us to accomplish this. If we can’t rely on the information you provide us, it may be unsafe to continue your treatment.
    6. I agree to provide my own sample of urine or saliva for drug testing promptly within 24 hours when directed. Drug testing helps you to be accountable to your goals for treatment, and it helps us understand how well your treatment is working for you. We will not continue telemedicine treatment if drug screens are being delayed, forged, tampered, or deliberately or repeatedly caused to be inaccurate.
    7. I agree not to fill any prescription for an opioid medication unless it is prescribed or specifically authorized by my provider, except in a medical emergency. Other opioid medications are crucial for us to know about due to their impact on your treatment.
    8. I agree to provide at least 24 hours’ notice to reschedule an appointment, and I understand that medication refills will only be provided during scheduled appointments. We will never provide a buprenorphine refill outside of a video-appointment during business hours. Please plan accordingly.
    9. I agree to work with my provider toward the goal of stopping all illicit drug use. We ask all patients to work with us toward this goal which, based on your unique treatment plan and preferences may include working with a counselor, therapist, support group, mental health provider, or another type of treatment program to compliment care by your provider. Our model works very well for most patients, but in the case where a patient is not progressing toward treatment goals we would refer to a more suitable program and discontinue telemedicine care.
    10. I agree to notify www.addictionology.center group in advance when I am going to be unavailable to complete a random drug screen or medication count. We want you to be free to travel and enjoy your life. Give us a heads-up in advance when you will be unreachable or unable to complete a drug screen, and we’ll accommodate all such reasonable requests. Exceptions to the advance notice requirement will be made for documented emergencies at the medical provider’s discretion.
    11. I agree to complete a medication count promptly within 24 hours when directed.

    Periodically we will verify that you have the correct number of tablets or films remaining which helps us understand that you’re taking and storing the medication safely as directed. Counts may be performed by video or photograph, per instruction of staff.

    1. I agree to store my medication in a safe, secure place where it’s not accessible to others and especially not accessible to children. In the event of medication loss or theft, a police report must be filed before we can consider replacing lost medication. A child who ingests buprenorphine may die from opioid overdose. If you are ever concerned about having a safe place to store your medication, talk to your provider who will advise you.
    2. I agree to provide prompt notice to www.addictionology.center group of any change in my contact or payment information. We want to avoid any interruptions in your care that may be caused by difficulty reaching you, covering costs, or sending drug tests to old or invalid addresses. We won’t know of changes unless you tell us, so do keep us informed.
    3. I agree to read all materials and ask any questions needed to help me understand them before signing anything. Agreements like this one are designed to ensure you know all about our program and what we need from you to continue a safe, convenient, and long-lasting treatment relationship.
    4. I agree not to openly display or use an illegal substance during my interactions with staff or providers. We’re happy to be able to serve patients in the comfort of their own homes. At the same time, telemedicine visits are also professional interactions like being in your medical provider’s office. Please help us create an environment of respect and professional dignity during your visits.
    5. I understand that my treatment plan is determined by my medical provider and will be modified based on my changing situation and needs. Your provider will develop the treatment plan collaboratively with you and will respect your preferences and decisions to every extent possible. Situations may occur when your preferred treatment is no longer medically safe. Failure to abide by this treatment agreement may lead your provider to determine that telemedicine-based buprenorphine is no longer safe and to refer to a different treatment setting.
    6. I understand that www.addictionology.center group does not directly provide any medical care. My physician provider provides medical assessment, treatment, and needed support for that treatment which may include referral when needed. There are several options and settings for treatment of problematic opioid use, and payment does not obligate any provider to recommend or provide a specific form of treatment such as buprenorphine. The appropriate treatment is always at the discretion of your provider.

    I agree to adhere to all the conditions above. I understand the policies listed above and I agree to comply with this aspect of my treatment plan. I understand that the failure to comply with any of the conditions above will be grounds for the termination of my treatment with www.addictionology.center group.

    I certify that I have carefully read, understand, and agree to the terms above, and I consent fully and voluntarily to this agreement. The undersigned is the patient, the patient's legal representative or is authorized by the patient to execute this form and accepts its terms.


    Code of Ethics

    All Users of the www.addictionology.center website acknowledge and accept the Code of Ethics Policy, which may be updated.

    All Center staff members (which includes contractors and interns)shall perform their duties in the context of this Code of Ethics and shall observe all relevant rules, laws and standards.

    • All staff memberswill review thisCode of Ethics and will abide by these principles.
    • All patients will this Code of Ethics and will abide by these principles.
    • ThisCode of Ethics is available to all stakeholders upon request andis posted on Center’s website.
    • Patients will be advised of the channels that are available to them for reporting ethical violations in the patient handbook and in the orientation session.

    Confidential Information

    The use of confidential information obtained as a consequence of employment or involvement as a contractor or internwith Center must be limited to the proper conduct of Center’s business.  All information about our patients is confidential and must never be disclosed to outsiders, except with the patient's written authorization or as allowed under federal and/or state law.  Neither Center nor any member of the Board of Directors or the staff may use, or permit others to use, confidential information for the purpose of furthering a private interest or as a means of making a profit.

    Responsibility to Patients

    This principal refers to practices and procedures of individual and/or group counseling relationships.

    • The primary obligation of Center’s staff membersis to respect the integrity and promote the welfare of the patient, whether the patient is assisted individually or in a group relationship.  In a group setting, staff members are also responsible for taking reasonable precautions to protect individuals from physical and/or psychological trauma resulting from interaction within the group.
    • The counseling relationship and information resulting from this relationship must be kept CONFIDENTIAL, consistent with the obligations of all Center staff.  In a group counseling setting the facilitator must set a norm of CONFIDENTIALITY regarding all group participants’ disclosures.
    • If a patient is already in a counseling relationship with another professional, staff membersmust attempt contact with that professional after obtaining aproper authorization to disclose protected health informationfor the exchange of relevant information regarding the patient in question. The contact, or theattempts to contact, shall be documented in the clinical record.
    • When the patient’s condition indicates that there is aclear and imminent danger to the patient or others, staff must inform responsible authorities (Duty to Warn) afterconsultation with the Executive Director, or his or her manager/
    • The solicitation or acceptance of commissions, fees, or anything of monetary value on the part a staff memberfrom patients, suppliers, or any other source as compensation for services routinely rendered to patients is not permitted.
    • Records of the counseling relationship, including interview notes, test data, correspondence, progress notes, and other documents are to be considered professional information for use in counseling and they are considered a part of the records of Center.
    • Revelation to individuals or organizations of apatient’s protected health information shalloccur with the written consent of the patient, unless the state or federal government allows or requires release of the information without the patient's written consent. Patients are given a copy of Center's Notice of Privacy Practices which describes how clinical information about them may be used and disclosed with and without their written authorization.
    • Use of data derived from a counseling relationship for purposes of counselor training or research shall be confined to content that can be disguised to ensure full protection of the identity of the patient.
    • In recognition of the fact that the relationship between staff members and patients is one in which the utmost discretion, good judgment and ethical behavior is of paramount importance, certain restrictions as to the scope of that relationship need to be carefully and strictly outlined and adhered to by all staff. This needs to be done in order to ensure the relationship’s integrity and therapeutic soundness. Therefore, activities such as in-kind payment for services (i.e. a patient offering free meals at his or her  restaurant to a counselor in exchange for counseling services), and financial transactions between staff members and patients such as lending/borrowing money, entering into loan agreements, formation of social relationships secondary to the ongoing therapeutic relationship, or the sponsoring of active patients are all considered to be unethical and are not to be engaged in by the staff member. Giving or lending items to patients such as tobacco products is also prohibited for all staff. Similarly if any staff member becomes aware of a colleague engaging in such activities, it is his or her responsibility to bring such issues and concerns to the Executive Director immediately.

    Ethical Conflicts

    • If a staff memberdetermines an inability to be of professional assistance to the patient, or perceives an ethical conflict, the staff member must bring this situation and its concerns to his or her supervisor.  The supervisor will determine the most appropriate action to be taken.
    • Staff memberswho have relatives, close friends, and/or business acquaintances who become Center patientswill excuse themselves from taking an active part in the treatment plan of such relatives, friends and acquaintances.  This is necessary to ensure objectivity in the service to such individuals.

     

    Responsibility to Colleagues

    Center staffshould treat colleagues with respect, courtesy, fairness and good faith.

    • Staffshould cooperate with colleagues to promote professional interests and concerns.
    • Staffshould respect ethical confidences shared by colleagues in the course of their professional relationships and transactions.
    • Staffshould create and maintain conditions of practice that facilitate ethical and competent professional performance by colleagues.
    • Any staff member having knowledge of unethical practices on the part of another colleague shall report such practices to Center’s Executive Director.
    • Staff memberswho replace or are replaced by a colleague in a professional practice should act with consideration for the interest, character, and reputation of that colleague.
    • Staff membersshould extend to colleagues of other professions the same respect and cooperation that is extended totheir staff colleagues.
    • Staff membersmay not use the work place for proselytizing for religious, political or economic purposes.

    Responsibility to Center

    Center staffshould adhere to commitments made to Center.

    • Staffshould work to improve Center’s policies and procedures, as well as the efficiency and effectiveness of its services.
    • All staff membersshould act to prevent discrimination of any kind at Center.  When serving in the capacity of a supervisor, leadership should act to prevent and eliminate discrimination at Center in work assignments and its employment policies and practices.
    • Staff membersshould use the resources of Center with scrupulous regard, and only for the purpose for which they are intended.


    Business Transactions

    All staff membersshould avoid representing Center in any transaction with any person, firm, corporation, or organization with which the staff member, or any member of the staff member’s family, has any material connection or in which he or sheowns a substantial interest.  Any such conflict needs to be brought to the attention of his or hersupervisor.

    Staff memberswho serve as an officer or a board member of any other organization, corporation, association, government entity, etc. shall not represent Center in any transactions with that same organization, corporation, association, or government entity in any contractual relationship without specific approval of the Executive Director.

    All transactions with outside suppliers should be conducted on a business-like basis in the best interest of Center.  Decisions should be governed by a customer-business relationship and not by personal friendship.

    Civic Activities:  Active participation by staff members in religious, community, professional or charitable organizations is encouraged.  Approval is not required to participate in or accept appointment as a trustee, director or officer of a non-profit organization unless there is some other potential conflict of interest between the organization and Center.

    Political Activities: A staff member may participate in political activities on his or her own time and in accordance with his or her individual desires and political preferences.  However, it must be clear at all times that a staff member’s participation is done as an individual and not as a representative of Center.  Before a staff member becomes a candidate or appointee to a public office, the staff member must advise his or her supervisor.

    Proprietary Knowledge: No staff member will share knowledge, facts, reports, written documents regarding Center methods, documents regardingprocedures or operations etc., without the expressed consent of the Executive Director.

    Because the primary responsibility of Center’s staffis to provide clinical services to Center patientsin accordance with best practices in addiction and mentalhealth treatment, Center discourages such outside activities as facilitation of outside therapeutic groups, or any other activity that proves to be adversely affecting the employee’s job performance at Center.  It is the obligation of every staff member, when contemplating participating in such outside activities, to first bring these issues to the Executive Director for his or herconsideration and appropriate recommendations.

    Marketing Ethics

    The Center Marketing Department, in addition to supporting and obeying laws and legal regulations pertaining to marketing and advertising extend and broaden the application of high ethical standards.  Specifically, we will not knowingly make marketing claims or create advertising that contains:

    • False or misleading statements or exaggerations
    • Testimonials that do not reflect the real opinion of the individual(s) involved
    • Price claims that are misleading
    • Claims insufficiently supported or that distort the true meaning of practicable application of statements made by professional or scientific authority
    • Statements, suggestions or graphics offensive to public decency or minority segments of the population.

    We recognize there are areas that are subject to honestly different interpretations and judgment.  Nevertheless, we agree not to use advertising that is in poor or questionable taste or that is deliberately insensitive.  These principles are based on the belief that sound and ethical practice is good business.  Confidence and respect are indispensable to our success and our relationship with clients and the public at large is dependent upon good faith.

    Outside Conflicts of Interest

    No outside activity must interfere or conflict with the interest of Center.  Acceptance of outside employment, election to directorships of other organizations, and participation in the affairs of outside organization carry possibilities of conflict of interest and shallbe discussed with the Executive Director before acceptance.

    No staff member of Center will be a director or officer of any other treatment facility or any other entity, which competes directly or indirectly with Center without prior approval of the Executive Director.

    Specified types of outside activities that raise conflict of interest or other difficult situations include, but are not limited to:

    • Being employed or contracted by a business, or personally engaging in any activity that is competitive with Center without specific approval of the Executive Director.
    • Using Center equipment, supplies, files, letterhead, or facilities for purposes other than Center related activities.
    • Personal conduct involving the use of mood altering substances; gambling or other activities during or outside of work hours which may prove embarrassing or reflect adversely upon Center or the professional staff memberin the conduct of his or her duties at Center.
    • Statements or circumstances that may imply sponsorship or support by Center of an outside employer or of a political, charitable, civic, religious, or similar organization when such is not the case.

    Professional Competence and Integrity

    Center staff members must bededicated to maintaining high standards of bothprofessional competence and integrity andwill do the following:

    • Staff memberswho: are convicted of felonies, are convicted of misdemeanors, engage in conduct which could lead to conviction of felonies or misdemeanors related to their qualifications or functions, are expelled from other professional organizations, or have their license or certificates suspended or revoked must report such activities or actions immediately to the Executive Director.
    • Center staff members recovering from a substance-use disorder, other than nicotine-related or caffeine-related disorders, must document continuous abstinence under independent living conditions or recovery housing for the immediate past two years prior to providing clinical services and must report any relapse during their time of providing clinical services at Center.
    • Staff memberswill seek appropriate professional assistance for their own personal problems or conflicts that are likely to impair their work performance or their clinical judgment.
    • Staff memberswill not engage in sexual relationships with current or past patients at any time.
    • Staff memberswho have direct contact with a particular patient or former patient of any Center program shallnot have, seek, or request a sexual relationship or sexual contact with that patient or former patient at any time.
    • Staff memberswho have not had direct contact with a particular patient or former patient of any Center program should not have, seek, or request a sexual relationship or sexual contact with that patient or former patient for a period of at least two years following that patient's receipt of Center services.
    • All staff membersshall not have or seek to have a personal, professional, or business relationship or contact with any patient for a period of at least two years following the patient's receipt of Center services.
    • Relationships between staff members and current or former patients or clients within Twelve Step recovery fellowships and other fellowships are sometimes unavoidable. In such cases, the relationships are to be maintained at a group level rather than a one-on-one level. These guidelines apply to the time a current or former patient participates in any Center program and for the period established for personal relations as noted above.
    • Staff memberswill not engage in verbal, emotional or behavioral harassment of patients, trainees or colleagues.
    • Staff memberswill not attempt to diagnose, treat or advise on problems outside recognized boundaries of their competence.
    • Under no circumstances, other than noted above, is a staff memberever to meet a patient, or former patient, or patient family member, outside of Center property unless participating in a Center sanctioned activity.  Additionally, no  staff membermay ever give a patient his or heror other Center past or current staff’spersonal cell phone number, home phone number, email address or any other means of contacting them outside of Center, including texting, social media resources (i.e. Facebook, MySpace, etc) within a two-year period following the patient’s discharge from treatment. Extenuating circumstances such as family member or associate known prior to starting into treatment may be an exception to this policy and counsel shallbe sought from the Executive Director regarding appropriateness of actions.
    • Staff memberswill attempt to prevent the distortion or misuses of their clinical findings.
    • Staff memberswill be aware that because of their ability to influence and alter the lives of others, they must exercise special care when making public their professional recommendations and opinions through testimony or other public statements.

    Responsibility to the Profession

    Staff membersrespect the rights and responsibilities of professional colleagues; and participate in activities which advance the goal of the profession.

    • Staff membersremain accountable to the standards of the profession when acting as members or employees of organizations.
    • Staff membersrecognize a responsibility to participate in activities that contribute to a better community and society.
    • Staff membersare concerned with developing laws and regulations pertaining to their field that serve the public interest, and with altering such laws and regulations that are not in the public interest.
    • Staff membersrecognize the need for continuing education and are open to new procedures and changes in expectations and values over time.
    • Staff membersrecognize that personal problems and conflicts may interfere with professional effectiveness.  Accordingly, they refrain from undertaking any activity in which their personal problems are likely to lead to inadequate performance or harm to a patient or colleague.  If engaged in such activity when they become aware of their personal problems, it is the staff member’s obligation to bring this to the attention of his or her immediate supervisor so that a determination can be made as to whether they should suspend, terminate or limit the scope of their professional activity.

    Witnessing of documents

    Unless approved by the Executive Director, or designee, no staff member shall act as witness to any document, for example. a will or advance directive, for a patient except Center generated forms. See Notary Services Policy for more information.  No document for outside use may be generated without direct Executive Director approval and countersignature.

    Candor with Management, Auditors, and Counsel

    Staff membersare expected to maintain complete and open communication with management regarding Center matters.  Any staff memberdeliberately concealing information or misleading management, auditors, or counsel shall be sanctioned up to dismissal and referral to a prosecutor for possible criminal justice action.

    Implementation of the Code of Ethics

    Difficult questions of judgment may arise in connection with thisCode of Ethics.  If any doubt exists regarding the propriety of an action or activity, the employee should seek advice and written approval from the Executive Director.  All staff membersare expected to promptly report the existence of any of their relationships, interest, or actions, which might violate or appear to violate thisCode of Ethics.

    Violations of the Code of Ethics

    Any suspected violations of thisCode of Ethics shallbe referred to the Executive Director.  Violations of this Code of Ethics may be grounds for disciplinary action, up to and including dismissal and referral to a prosecutor for possible criminal justice action. In situations where infractions of the Code may have violated federal or state law, such infractions will be disclosed as appropriate, and reported to enforcement agencies as required.




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