Please read the text below then sign at the bottom to provide consent for treatment.
What is PursueCare?
PursueCare LLC partners with doctors, therapists, counselors, and an addiction recovery pharmacy to provide individuals diagnosed with Substance Use Disorder with Medication-Assisted Treatment (MAT) using telehealth/telemedicine (private and secure live video conferencing). Telehealth provides patients more treatment opportunities at times and locations that meet the patient’s needs. MAT employs medication management, individual physician visits, and therapy or counseling, along with pharmacy services. Our partnering providers team with us to coordinate care with hospitals, clinics, primary care doctors, and other substance use treatment providers, as well as to provide treatment options directly to individuals via a smart phone application. Patients are welcome to sign up for services on their own, or upon the referral of their health care provider. PursueCare Care Coordinators are available to assist patients in their PursueCare experience, including confirming payment options like insurance coverage.
MAT is the gold standard for treating opiate dependence and Opioid Use Disorder. It reduces annual mortality by one-third, reduces infections transmitted by IV drug use, and decreases healthcare costs. Buprenorphine medications like Suboxone can help patients reduce the physiological symptoms of withdrawal and escape the constant daily cycle of using illicit drugs.
Medication is just one tool to use on the path to recovery. Patients must work hard to participate on many levels, including active participation in sessions with their MAT Prescribers and with their therapist/counselor. These sessions are essential for building the skills needed to maintain recovery. Patients are asked to abstain from alcohol during MAT due to the increased risk for central nervous system and respiratory depression from the combination of buprenorphine and alcohol. Patients may need to go to a lab for urine toxicology screens and/or blood work if state regulations require it or if the MAT Prescriber recommends it for treatment purposes. Patients may also need to attend an in-person session with their MAT prescriber if state regulations require it. If medical issues or behavioral health issues are uncovered that cannot be treated via PursueCare’s telehealth model, our Care Coordination team will assist patients in finding a primary care provider or other additional resources.
PursueCare is not recommended for emergency treatment services. If a patient is in immediate danger of harm to him/herself or others, including if the patient is at immediate risk of an overdose or experiencing an overdose, the patient or a loved one should immediately call 9-1-1 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).
Informed Consent to Screen, Evaluate and Treat
As a patient of PursueCare, I have the right to make informed decisions regarding my care. My rights include being informed of my health status, being involved in care planning and treatment, and being able to request or refuse treatment. PursueCare healthcare professionals will discuss with me the nature of my symptom(s) and condition(s), the proposed treatment(s), the benefits and risks associated with treatment, the probability of successful outcomes, and alternatives to the proposed treatment(s), if any or as applicable. I acknowledge and understand that I may revoke consent to further care at any time by informing email@example.com or my PursueCare healthcare professional of my desire to do so.
By accepting screening, evaluation, and treatment from any PursueCare healthcare professional, I authorize providers using the PursueCare platform to perform all clinical and professional treatment and services deemed necessary in their determination in order to ensure program outcomes/appropriateness, and acknowledge that I have been informed of the benefits and risks of such treatment and services by the PursueCare healthcare professional(s) providing my care.
I agree to submit urine and/or take alcohol and other drug and toxicology testing, if requested by my PursueCare provider. I understand that failure to do so could result in discharge from care. Urine/alcohol results may be utilized as treatment interventions or may be completed as determined by external requirements. I agree to submit to screening for therapy/counseling, and subsequent therapy/counseling, if it is deemed clinically necessary to do so by my PursueCare MAT prescriber. I understand that failure to do so could result in discharge from care. I understand that if I fail to follow any communicable disease-related referrals, PursueCare and/or its partnering providers will need to report such to applicable health authorities pursuant to state law.
I have been advised and understand that PursueCare and its partnering providers adhere to all state and federal laws of confidentiality, including confidentiality of your personal information (i.e. protected health information, or “PHI”) pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), and any suspected violations of the law must and will be reported. PursueCare and its partnering providers are, behavioral health and addiction treatment providers, and will not disclose with anyone any information regarding your treatment or your PHI, other than what HIPAA authorizes for coordination of care, emergency care, quality management, insurance verification, or claims payment purposes, unless you specifically authorize PursueCare to do so in writing. You have been provided with a copy of Pursuecare’s Notice of Privacy Practices with this Consent. You may also review Pursuecare’s Notice of Privacy Practices at any time by visiting https://www.pursuecare.com/NOPP or requesting a copy from a PursueCare representative at firstname.lastname@example.org.
Information received from minors is not generally shared with parents without permission. Patients are allowed to access their file and patient information.
I give my consent for the duration of my treatment and 90 days after discharge for PursueCare and its partnering providers to release information regarding my progress and location in treatment to referring agencies and healthcare providers, as well as probation and officers of the Court (if applicable) for the purpose of assuring compliance with an order for treatment (if requested).
Federal regulations do not protect from disclosure information related to a patient’s involvement in a crime. We are required to report suspected abuse to children, those who are disabled, or the elderly. Information may be shared in times of medical emergency. If required by a court order signed by a judge, information will be released at that time. If a patient shares a specific plan or intent to harm themselves, that information may be shared.
In case of severe medical emergency, I have listed an emergency medical contact on my PursueCare account, or on a release form, and authorize PursueCare and/or its partnering providers to contact that party should such an emergency occur.
Consent for Telehealth Treatment
I understand that Telehealth/Telemedicine (“Telehealth”) means that I will be able to consult with a PursueCare healthcare provider about my health and medical concerns/needs through an interactive electronic video connection, and my PursueCare healthcare provider will be able to screen, evaluate, and treat me via such a connection. I further understand that Telehealth involves the use of electronic communications, software, and systems to enable healthcare providers at different locations to share individual PHI. The electronic software, systems, and equipment used to facilitate my care will incorporate industry-standard and HIPAA-compliant network, software, and hardware security features and protocols to protect the confidentiality of my identity and PHI, and will include measures to safeguard data transmitted, as well as ensure its integrity against intentional or unintentional breach/corruption.
My healthcare provider and/or PursueCare has explained to me how the Telehealth technology will be used for my treatment and services.
The benefits of Telehealth include, but are not limited to:
I understand there are potential risks with Telehealth may include:
I give my consent to utilization of Telehealth, and being interviewed by the consulting health care provider via Telehealth. I also understand other individuals may be present to assist with technology use, including another healthcare provider and/or telepresenter, and that they will take reasonable steps to maintain confidentiality of any information obtained. I acknowledge that I have been adequately informed of Telehealth’s risks and benefits, and further understand that I have the right to ask my healthcare provider to discontinue use of Telehealth at any time, but that such a request may result in discharge from care by PursueCare and its partnering providers.
I hereby release PursueCare and its partnering providers and any other person participating in my care from any and all liability which may arise from the taking and authorized use of backups, data, videotapes, digital recordings, films, audio, and photographs.
I have the right to delegate my right to make informed decisions to another person. To the degree permitted by state law, and to the maximum extent practicable, PursueCare must respect my wishes and follow that process. In the case that I am unable to make medical decisions because I am unconscious or otherwise incapacitated, PursueCare may consult with my advance directives, medical power of attorney, patient representative, or emergency contact, if any of these are available. In such cases, relevant information will be provided to the applicable representative so that informed health care decisions can be made for me. As soon as I am able to be informed of my rights regarding my treatment, PursueCare will provide that information to me.
By accepting treatment from PursueCare and its partnering healthcare professionals, I authorize the release of any PHI or other information regarding my treatment to any insurance carrier or other applicable third-party payor or financially responsible entity or individual for the purpose of securing payments for services rendered to me, and assign and set over to PursueCare any benefits for the cost of treatment that I may be entitled to as a result. I further authorize the third-party payor to make payment directly to PursueCare.
Patient Financial Responsibility
By accepting treatment from PursueCare or a partnering healthcare professional, I acknowledge and accept financial responsibility for all charges for any and all services rendered to me. Before my first session with a PursueCare partnering provider, I understand that I will be required to provide either my current insurance coverage information and/or a valid credit card. This information is not required at the time of registration for PursueCare services, but will be required before treatment and services begin.
Patients paying “out-of-pocket” for treatment must pay in full at the time of service. Payment is accepted via most major credit cards.
While insurance may confirm my benefits, I understand that confirmation of benefits does not guarantee coverage and agree that I am ultimately responsible for any unpaid balance due for services otherwise covered by insurance. It is my responsibility to know if my insurance has any deductible, co-payment, co-insurance, out-of-network limit, prior authorization requirement, or limitation for services received, and I understand that I must make payment in full for these services that are not covered at the time of service or upon receiving a statement of account from PursueCare.
PursueCare will make reasonable efforts to confirm insurance, obtain prior authorizations, and obtain referrals as may be required by my insurance carrier. I understand and agree that it is my responsibility to know if my insurance carrier requires a referral from my primary care physician and that it is up to me to obtain the referral if PursueCare cannot obtain the referral directly on my behalf. I understand that without this referral, my insurance may not pay for any services and that in such cases I will be financially responsible for all services rendered to me, and filing any claims or appeals against my insurance for reimbursement.
I understand and agree that I am required to update my insurance on file with PursueCare and/or inform a PursueCare representative at email@example.com upon any changes in my insurance coverage. If my insurance has changed or is terminated at the time of service, I agree that I am ultimately financially responsible for the balance in full.
Understanding the financial policy contained here is an important part of your responsibility as a patient. Patients are welcome to ask questions about the financial policy at any time or about financial assistance programs that may be available to them by contacting a Care Coordinator at firstname.lastname@example.org. Patients are responsible for the timely payments of all balances on their accounts.
If you are a Medicare or Medicaid patient, in order to receive treatment you must provide to PursueCare, or ensure your referring provider has provided, both your Medicare/Medicaid ID card and, if applicable, your secondary insurance ID card. If PursueCare does not receive the proper information for a secondary insurance, any such insurance will not be billed. It will be your responsibility to pay the balance and then file a claim with such insurance for reimbursement.
I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE CONSENT TO FURTHER PURSUECARE OR PURSUECARE PARTNERING PROVIDER TREATMENT AT ANY TIME BY INFORMING A PURSUECARE REPRESENTATIVE OR MY PROVIDER OF MY DESIRE TO DO SO. HOWEVER, SUCH REVOCATION SHALL NOT AFFECT ANY TREATMENT, SERVICES, DISCLOSURES OR OBLIGATIONS ALREADY MADE IN COMPLIANCE WITH YOUR PRIOR CONSENT TO TREATMENT. PURSUECARE PROVIDES THIS NOTICE TO ITS PATIENTS IN ORDER TO COMPLY WITH HIPAA, THE CENTERS FOR MEDICARE & MEDICAID SERVICES, AND ANY APPLICABLE STATE AND FEDERAL LAWS.
This Notice is effective June 25, 2019
Telemedicine HIPAA Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Telemedicine HIPAA Notice of Privacy Practices (the "Notice") is being provided to you by PAI Holding Company LLC, as that entity or its subsidiaries and affiliated entities may be formed and incorporated in your state, and the employees and practitioners that work at such entity and/or for such practices, and/or are contracted to provide care in coordination or partnership with such entity and/or for such practices (collectively referred to herein as “PursueCare,” “We,” or “Our”). It contains important information regarding your medical information. You also have the right to receive a paper copy of this Notice and may ask us to give you a copy of this Notice at any time. If you received this Notice electronically, you are still entitled to a paper copy of this Notice upon your request. You can request a paper copy of our current Notice from the Privacy Officer at 877.742.6992, or you can access it on our website at https://www.pursuecare.com.com/NOPP.
The Health Insurance Portability and Accountability Act of 1996 ("HIPAA") imposes numerous requirements on health care practices such as ours, defined as Covered Entities, regarding how certain individually identifiable health information – known as protected health information or “PHI” – may be used and disclosed. We understand that medical information about you and your health is personal. We are committed to protecting medical information about you and will use it to the minimum necessary to accomplish the intended purpose of the use, disclosure or request of it. As required by law, this notice provides you with information about your rights and our legal duties and privacy practices with respect to the privacy of PHI. This notice also discusses the uses and disclosures we will make of your PHI. We must comply with the provisions of this notice as currently in effect, although we reserve the right to change the terms of this notice from time to time and to make the revised notice effective for all PHI we maintain.
PERMITTED USES AND DISCLOSURES
We can use or disclose your PHI for purposes of treatment, payment, and health care operations. For each of these categories of uses and disclosures, we have provided a description and examples below. However, not every particular use or disclosure in every category will necessarily be listed.
OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
We may also use your PHI in the following ways:
Subject to the requirements of applicable law, we will make the following uses and disclosures of your PHI:
CONFIDENTIALITY OF MENTAL HEALTH, HIV, ALCOHOL, AND DRUG ABUSE PATIENT RECORDS
PHI related to your mental health, psychotherapy notes, HIV, genetic information, alcohol and/or substance abuse records, and other specially protected health information may enjoy certain heightened confidentiality protections under HIPAA and applicable state and federal law. Any disclosure of these types of records will be subject to these special provisions.
In the case of psychotherapy notes (i.e., notes that have been recorded by a mental health professional documenting counseling sessions and have been separated from the rest of your medical record) and alcohol and/or substance abuse records, the confidentiality of such PHI maintained by us is protected by federal law and regulations. Generally, we may not say to a person outside the facility you reside in where our care occurs that you attend psychotherapy or alcohol and/or substance abuse treatment, or disclose any information identifying you as receiving psychotherapy, or as an alcohol or drug abuser, unless:
Violation of federal law and regulations by a alcohol and/or substance abuse program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations.
Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime. Disclosure may be made concerning any threat made by a patient to commit imminent physical violence against another person to the potential victim who has been threatened and to law enforcement.
Federal law and regulations do not protect any information about suspected child or elder abuse or neglect from being reported under applicable state law to appropriate state or local authorities.
When you sign a release of information regarding your psychotherapy notes and alcohol and/or substance abuse, or an authorization, it may later be revoked, provided that the revocation is in writing. The revocation will apply, except to the extent we have already taken action in reliance thereon.
OTHER USES OF YOUR HEALTH INFORMATION
Certain uses and disclosures of PHI will be made only with your written authorization, including uses and/or disclosures:
You have the right to request restrictions on our uses and disclosures of PHI for treatment, payment and health care operations. However, we are not required to agree to your request unless the disclosure is to a health plan in order to receive payment, the PHI pertains solely to your health care items or services for which you have paid the bill in full, and the disclosure is not otherwise required by law. To request a restriction, you may make your request in writing to the Privacy Officer.
You have the right to reasonably request to receive confidential communications of your PHI by alternative means or at alternative locations, including electronically. To make such a request, you may submit your request in writing to the Privacy Officer.
You have the right to inspect and copy the PHI contained in our provider records, except for:
In order to inspect or obtain a copy of your PHI, you may submit your request in writing to the Privacy Officer or Medical Records Custodian. If you request a copy, we may charge you a fee for the costs of copying and mailing your records, as well as other costs associated with your request.
We may also deny a request for access to PHI under certain circumstances if there is a potential for harm to yourself or others. If we deny a request for access for this purpose, you have the right to have our denial reviewed in accordance with the requirements of applicable law.
You have the right to request an amendment to your PHI but we may deny your request for amendment, if we determine that the PHI or record that is the subject of the request:
In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records. In order to request an amendment to your PHI, you must submit your request in writing to the Medical Record Custodian, along with a description of the reason for your request.
You have the right to receive an accounting of disclosures of PHI made by us to individuals or entities other than to you for the six years prior to your request, except for disclosures:
To request an accounting of disclosures of your PHI, you must submit your request in writing to the Privacy Officer. Your request must state a specific time period for the accounting (e.g., the past year). The first accounting you request within a twelve (12) month period will be free. For additional accountings within twelve (12) months of the first request, we may charge you for the costs of providing the list. We will notify you of the costs involved, and you may choose to withdraw or modify your request at that time before any costs are incurred.
You have the right to receive a notification, in the event that there is a breach of your unsecured PHI, which requires notification under the Privacy Rule.
NOTICE REGARDING USE OF TECHNOLOGY
We may use electronic systems, software, services, and equipment, including without limitation email, video conferencing technology, cameras, audio recording devices, cloud storage and servers, internet communication, cellular networks, smart phone applications, voicemail, facsimile, electronic health record, and related technology (“Technology”) to share PHI with you or third-parties subject to the rights and restrictions contained herein. In any event, certain unencrypted storage, forwarding, communications and transfers may not be confidential. We will take measures to safeguard the data transmitted, as well as ensure its integrity against intentional or unintentional breach or corruption. However, in very rare circumstances security protocols could fail, causing a breach of privacy or PHI.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice at any time, for any reason permissible by law. We reserve the right to make the revised or changed Notice effective for PHI and medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice at https://www.pursuecare.com.com/NOPP and provide copies to the facilities we coordinate care with. The Notice will contain on the first page, in the top right-hand corner, the effective date.
If you believe that your privacy rights have been violated, you should immediately contact the Privacy Officer at 860.215.2295. We will not take action against you for filing a complaint. You also may file a complaint with the Secretary of the U. S. Department of Health and Human Services.
If you have any questions or would like further information about this Notice, please contact the Privacy Officer, Nicholas Mercadante at 860.215.2295
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