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⦁ Practice Description/Expectations/Suboxone Contract/Therapy Services Notice ⦁ Client Rights/HIPAA ⦁ Assignment of Benefits ⦁ Telemedicine Consent Form ⦁ Appointment Reminders Consent Form
Thank you for giving us the opportunity to be a part of your journey towards a greater sense of wellness and quality of life.
We are a primary, addiction and mental health clinic who specialize in high quality, compassionate care provided by trained addiction and mental health professionals. We are here to assist you with your recovery and to stabilize any co-occurring mental health concerns that you may have.
We believe that everyone can achieve sobriety and live a life of health and happiness. The BlueHorn Medical Center treatment model is based on highly individualized medical and clinical care, including, but not limited to, medication management, counseling, therapy, and neuropsychiatric testing. Our goal is to help diagnose and treat the underlying causes that may lead to and can perpetuate an individual’s addiction to substance.
As a patient with BlueHorn Medical Center, you will meet with one of our medical clinicians to get a detailed account of your past addiction, psychiatric and medical history. This will allow us to make a comprehensive plan for your care right at the onset of treatment.
Following your initial visit, our medical, addiction and psychiatric team will formulate a highly specialized plan that addresses your treatment goals, therapy needs, and frequency of follow-up appointments.
As always, your engagement in the treatment and therapy process will be key to our success as a team!
At BlueHorn Medical Center we are all committed to being an integral part of your health and prosperity.
Sincerely,
Shakleen Shakur, APRN, FNP-BC, PMHNP-BC
Abass Jafuneh DNP, APRN, PMHNP-BC
As a participant in the controlled substance treatment agreement for substance use disorder(s), I agree to the following:
⦁ To keep all my scheduled appointments or change the appointment in advance, except in case of emergency. ⦁ I agree not to sell, share, or give any of my medication to another person. ⦁ I agree not to sell or buy drugs at BlueHorn Medical Center, or in its parking lots or property. ⦁ I agree that my medication/prescription may only be given to me at my regular office visits. A missed visit may result in my not being able to get my medication/prescription until the next scheduled visit. ⦁ I agree that the medication I receive is my responsibility and I agree to keep it safe and secure. I agree that lost/stolen medication will not be replaced regardless of why it was lost or stolen. ⦁ I agree not to obtain the controlled substance being prescribed, suboxone/subutex, other opioids, stimulants, or benzodiazepines (for example, lorazepam, diazepam/Valium, clonazepam, alprazolam/Xanax, etc.) from any other healthcare clinicians, pharmacies, or other sources without telling my treating clinician. ⦁ I understand that mixing the controlled substances I am being prescribed with other medications or alcohol, can be dangerous, leading to possible overdose and death. ⦁ I understand that the controlled substance being prescribed by itself is not enough treatment for my addiction, and I agree to participate in counseling/support groups as discussed and agreed upon with my healthcare clinician. I understand that if my attendance at these groups is not confirmed then I may not be able to continue to receive the controlled substance being prescribed, if applicable. ⦁ I agree to provide random urine samples for drug testing whenever I am asked to do so, and understand that prescriptions will NOT be given unless a drug screen has been collected. ⦁ I agree that my goal is to stop using addictive drugs, and that I will work to stop using all addictive and illegal substances during my treatment with the controlled substance being prescribed. ⦁ I agree that violating this agreement may result in my no longer receiving treatment with the controlled substance being prescribed. ⦁ I understand that if I decrease my use of illicit substances (ie.,stop using heroin, pain pills, etc) or substitute the prescribed medication for these drugs, I have a higher risk of dying from an overdose if I relapse. ⦁ I understand that the controlled substance being prescribed is extremely dangerous for infants and children. They can stop breathing and die after taking even small amounts of this medication. I agree to keep my supply of this medication locked securely away from others, especially infants and children. If a child/infant gets into the medication call 911 immediately. ⦁ If you become pregnant please contact BlueHorn Medical Center immediately as your medication may need to be adjusted.
⦁ Each patient is encouraged to have a primary care provider. We will ask your permission to sign a release of information for each provider you are seeing to help us best coordinate your care. If you are on probation a Release of information is required. ⦁ During your treatment, certain labs and/or tests may be requested, such as; blood work or an EKG. You will need to seek this from your primary care provider and provide the results in a timely manner. If BlueHorn Medical Center believes this is critical information to be obtained from other clinicians and you refuse to sign a Release of Information, you may be considered inappropriate for outpatient treatment and referred to a higher level of care (i.e. inpatient treatment or residential). ⦁ Do not use alcohol, illegal drugs or substances, or medications that are not prescribed for you. ⦁ Do not misuse prescription medications. ⦁ Notify the clinician of all medications you are taking or have been prescribed. ⦁ All sedatives are dangerous and when taken with controlled substances, if prescribed, could result in death. ⦁ Do not increase or decrease the controlled substance being prescribed unless directed by your clinician. ⦁ Take medications as prescribed. ⦁ Provide drug screens and/or pill/film counts as requested by your clinician. ⦁ Follow clinic rules, including be on time appointments. If later than 15 minutes, please call the clinic as we may need to reschedule. ⦁ Call the clinic immediately should you relapse. ⦁ If you have a positive drug screen, fail a pill/film count, or relapse you will be required to be seen more frequently in the clinic to help provide better care during your recovery. ⦁ If you are prescribed a medication such as naltrexone, suboxone, or subutex, please remember that if you are injured or need pain medication that it will not be as effective while taking these medications. ⦁ Please coordinate with your clinician and your treating provider if there is an upcoming surgery planned and anesthesia is required. ⦁ disability/Medical/legal Forms require an appointment to discuss the form and completion is at the discretion of the clinician.
⦁ Three inappropriately positive or negative urine tests within 3 months - you will be referred to a higher level of care. Upon completion you may be allowed to return to the clinic at the clinician’s discretion. ⦁ After 3 cancellations, no shows, or rescheduling of appointment with 24 hours of the appointment time for ANY clinician (i.e. therapist, MD, Psychologist) within 3 months, we will have you meet with a member of our team to discuss barriers to care and determine a re-engagement plan prior to being able to schedule a clinician visit. Once this is completed, you will be able to resume visits with the providers as before. ⦁ Abusive or threatening behaviors to staff or clinician. ⦁ Illegal or disruptive behavior ⦁ Not following recommendations of treatment ⦁ Diversion or suspected diversion of medications ⦁ Patient requires a higher level of care ⦁ Failure to comply with random drug screens and /or film/pill counts
If you are discharged from BlurHorn Medical Center, you are responsible for finding your own clinician. No prescriptions will be given at the time of discharge.
If you have a medical emergency, please call 911 or go to the nearest emergency room. Messages are NOT checked after the clinic has closed during the weekdays, on the weekend or on holidays. If you have questions that can wait, please come prepared and discuss with your provider during your visit. Otherwise leave a brief message and staff will return your call within 24 hours. If you have questions about your medications, please contact your pharmacy first.
Please call the pharmacy for questions about medications first. All prescriptions are e-prescribed to your pharmacy following your visit. Please do not change your pharmacy unless necessary as it can cause disruption in receiving your medications. As a service, we will do prior authorizations. Please allow 72 business hours for processing.
I hereby acknowledge that the specimen that I provide is my own and has not been adulterated. I authorize Quest Diagnostics to analyze the specimen and release the test results to the ordering practitioner. By signing this authorization, I acknowledge that I am financially responsible for all co-pays, deductibles, and any amounts not covered by insurance, and I authorize my physician and/or staff to release any information necessary to Quest Diagnostics, and Affiliates to determine benefits for laboratory services. If self-pay, I accept full responsibility for all payments associated with lab services.
BlurHorn Medical Center accepts most insurance payers.
Co-pays are due at the time of your appointment. Your insurance will be charged for services received. You are responsible for all patient balance due to co-pays, co-insurances, deductibles, billing charges, laboratory, and psychological testing, etc. Insurance and billing statement questions.
Self-pay payments are due at the time of appointment
Cash, check and credit card are accepted for payment. If a check is returned for insufficient funds a fee of $50.00 will be assessed and required to be paid prior to the next visit.
involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care providers, specialists and/or subspecialists, and other healthcare providers who are part of my clinical care team. The information may be used for diagnosis, therapy, follow-up and/or education, and may include the following:
⦁ Progress reports, assessments, or other interventions-related documents ⦁ Bio-physiological data transmitted electronically ⦁ Videos, pictures, text messages, audio and any digital form data ⦁ The laws that protect the privacy and confidentiality of health and care information also apply to telehealth/telemedicine. Information obtained during telehealth/telemedicine that identifies me will not be given to anyone without my consent except for the purposes of treatment, education, billing and healthcare operations. By agreeing to use the telehealth/telemedicine services, I am consenting to BlurHorn Medical Center sharing of my protected health information with certain third parties as more fully described in BlurHorn Medical Center Policy. I understand, agree, and expressly consent to BlurHorn Medical Center obtaining, using, storing and disseminating to necessary third parties, information about me, including my image, as necessary to provide the telehealth/telemedicine services.
As with any Internet-based communication, I understand that there is a risk of security breach. Electronic systems used 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.
Telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the Internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference) that prevent effective interaction between consulting clinician(s), participant, patient or care team.
I hereby release and hold harmless BlurHorn Medical Center and all members of my care team from any loss of data or information due to technical failures associated with the telehealth/telemedicine service.
I understand and agree that the health information I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not have access to my full medical record or information held at BlurHorn Medical Center.
I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit.
I have the right to withhold or withdraw consents to the use of telehealth/telemedicine services at any time and revert back to traditional in-person clinic services. I understand that if I withdraw my consent for telehealth/telemedicine, it will not affect any future services or care benefits to which I am entitled.
By signing below, I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or otherwise legally authorized to consent. I have carefully read and understood the above statement. I have had all my questions answered. I understand that this information consent will become a part of my medical record.
I certify that I am fluent in the language of the person providing consent. I certify that I have accurately and completely interpreted the consent of this form, and that the person giving consent has indicated their understanding of the consents.
I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act (HIPAA) of 1996, 4 CFR Parts 160 & 164 , Subparts A & E and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand the information to be released may include records related to behavioral and/or mental health care and/or alcohol and drug abuse treatment. This authorization may be revoked at any time except to the extent that BlurHorn Medical Center has already acted in reliance on it. BlurHorn Medical Center will not condition care on whether I sign the authorization. Information used/disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal law. It is understood that where federal laws and state laws relating to the court system apply, they should take precedence over any expiration or revocation expressed. I understand this realize with termination in one year unless specified here:
BlurHorn Medical Center utilizes an automated Patient notification system to notify patients of their upcoming appointment(s) quickly and efficiently. In order to receive automated message reminders from BlurHorn Medical Center, Federal law requires prior expressed written consent (PEWC) allowing BlurHorn Medical Center to distribute automated communication to your mobile device.
I, __________________________________________ (print patient/guardian name), Consent to receive automated text messages or short message service (SMS) from BlurHorn Medical Center at (_____)___________________ and /or my email: _____________________ By signing, I certify that I am the owner of the wireless device designated as the primary contact on the patient information form.
Please be advised, you may revoke your consent to receive automated messaging at any time. Wireless carriers require us to inform clients changes may be incurred.
I authorize my insurance benefits to be paid directly to BlurHorn Medical Center and affiliates. I acknowledge that my insurance plan may change from month-to-month, and I understand that this consent covers any and all insurance plans I have during care at BlurHorn Medical Center. I authorize the use of this signature on all my insurance submissions whether manual or electronic.
I hereby authorize release of information necessary in the processing of payment for my care at BlurHorn Medical Center. This release shall authorize release of information to my insurance carrier, its utilization review organization and/or other parties involved in the processing of payment for my care including my primary care physician.
I understand that I need not consent to release of information in order to obtain services. I choose to do so willingly and voluntarily for the purpose(s) specified above.
The duration of this authorization is for the duration of care and will expire when my account is paid in full. I understand that I may revoke this consent at any time by notifying BlurHorn Medical Center billing office or the Minnesota Department of Health office of Health Facility Complaints in writing.
I understand that BlurHorn Medical Center cannot guarantee information received from insurance verification, and that said verification is no guarantee of payment. I also understand that I am personally responsible for unpaid patient responsibility balances on my account and if my insurance plan requires a referral authorization for my appointments, it’s my responsibility to obtain a referral prior to appointment. There will be a $25.00 return check fee on returned checks. It is understood that if there are questions relating to claim processing, reimbursements, denials, balances owed, or payment is denied for coordination of Benefits Assignment, I give full consent to BlurHorn Medical Center to contact and/or speak with the insurance policy holder(s).
I understand that my care records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided by the regulations.
I understand that I may revoke this authorization at any time except to the extent that action has been taken in reliance on it. Unless I revoke my consent earlier, this consent will expire automatically as follows: ONE YEAR FROM SIGNATURE DATE OR WHEN ACCOUNT IS PAID IN FULL, whichever is later.
By signing this form, I consent to and authorize BlurHorn Medical Center to assess and treat me. I understand that BlurHorn Medical Center is available to explain the purpose of the services and that I have the right to refuse the recommended services. Services may include face-to-face or telemedicine.
I agree to release my medical information to be viewed within BlurHorn Medical Center to coordinate my care. This includes release to any of BlurHorn Medical Center business Associates for purposes of my services and for business operations. I also agree that BlurHorn Medical Center can release my medical records to accrediting or regulatory agencies if those agencies request my records as allowed by the law.
I consent to the disclosure of my protected health information for the purpose of payment, treatment, and program operations. I request that payment of authorized benefits be made to BlurHorn Medical Center on my behalf for any services furnished to me by BlurHorn Medical Center. I assign the benefits payable for services to the organization furnishing the services.
I acknowledge that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow-up among providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers, a list is available upon request. If I would like a copy of BlurHorn Medical Center privacy form, I will ask for one. I understand that my health records will not be used for research without my permission as described in the Privacy Notice. However, for the purpose of improving BlurHorn Medical Center services and program planning, my health data may be used in aggregate by the program for evaluation purposes.
I authorize BlurHorn Medical Center and its affiliates, its employees and agents, to exchange my personal health information (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me which includes but is not limited to my name, address, social security number, member ID number). It is understood that if there are questions relating to claims processing, reimbursement, denials including Coordination of Benefits, I give BlurHorn Medical Center full consent to contact and/or speak with the insurance policy holder(s).
I also authorize any third-party payer having responsibility for payment of charges for medical, mental health and/or laboratory services to review my personal health information for the purpose of helping me to resolve claims and health benefits coverage issues. I understand that communication can occur verbally, in person, written questionnaires, and mailed, faxed or secure email correspondence.
My health information is protected by federal regulation (Alcohol and Drug Abuse Patient Records, 42 CFR part 2: and/or HIPAA 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances described in BlurHorn Medical Center Privacy Notice.
I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. BlurHorn Medical Center clinic’s Notice outlines the procedure for revocation. This authorization will expire when I terminate services with BlurHorn Medical Center or unless I request an earlier expiration in writing.
For disclosures other than for medical, mental health, and laboratory services, payment and healthcare operations purposes, care may not be conditioned on my agreement to sign and authorization (unless I am receiving care solely to create protected health information for disclosure to a third party) (45 CFR & 164.508 (b)(4)(III).
