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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.
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:
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.
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.
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.
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”).
I further acknowledge and understand the following:
www.addictionology.center and its affiliated medical groups are committed to providing the best quality healthcare services.
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).
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.
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.
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
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.
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.
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.
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.
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.
This principal refers to practices and procedures of individual and/or group counseling relationships.
Center staff should treat colleagues with respect, courtesy, fairness, and good faith.
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 she owns a substantial interest. Any such conflict needs to be brought to the attention of his or her supervisor.
Staff members who serve as an officer or board members of any other organization, corporation, association, government entity, etc. shall not represent the 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 the 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 regarding procedures or operations, etc., without the expressed consent of the Executive Director.
Because the primary responsibility of the Center’s staff is to provide clinical services to Center patients in accordance with best practices in addiction and mental health treatment, the Center discourages such outside activities as the 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 her consideration and appropriate recommendations.
The Center Marketing Department, in addition to supporting and obeying laws and legal regulations pertaining to marketing and advertising, extends and broaden the application of high ethical standards. Specifically, we will not knowingly make marketing claims or create advertising that contains:
We recognize there are areas that are subject to honestly different interpretations and judgments. 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.
No outside activity must interfere or conflict with the interest of the Center. Acceptance of outside employment, election to directorships of other organizations, and participation in the affairs of the outside organizations carry possibilities of conflict of interest and shall be discussed with the Executive Director before acceptance.
No staff member of the Center will be a director or officer of any other treatment facility or any other entity, which competes directly or indirectly with the Center without the 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:
Center staff members must be dedicated to maintaining high standards of bothprofessional competence and integrity andwill do the following:
Staff members respect the rights and responsibilities of professional colleagues; and participate in activities that advance the goal of the profession.
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.
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.
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.
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.