Consent To Treat Form - PursueCare

Consent To Treat Form

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 support@pursuecare.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.

    Medical Records/Confidentiality

    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 support@pursuecare.com.

    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:

    1. I may not need to travel to the consult location.
    2. I have improved access to a specialist through this consultation.
    3. I have flexibility in scheduling around work, family, and other personal obligations.
    4. I receive more efficient screening, evaluation, and treatment.

    I understand there are potential risks with Telehealth may include:

    1. The video connection may not work due to technical or connectivity issues, or that it may stop working during the consultation, resulting in delays in treatment.
    2. The video picture or information transmitted may not be clear enough to be useful for the consultation, resulting in delays in treatment.
    3. In very rare circumstances security protocols could fail, causing a breach of privacy or PHI.
    4. I may be required to go to the location of the consulting provider if it is felt that the information obtained via Telehealth was not sufficient to make a diagnosis, if state or federal regulations require an in-person session, or my physical presence is required to access specific medications or services.

    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.

    Consent for Consultation with Relevant Specialists - Behavioral Health Integration and Collaborative Care Management

    I understand that my PursueCare health provider and/or supporting and coordinating PursueCare staff may consult with relevant specialists related to my care, including psychiatric consultants, pharmacy professional staff, laboratories, primary care or referring health providers, and health care personnel who may collaborate or affiliate with PursueCare for my overall health care needs, and/or referred me to PursueCare’s health services. These services are broadly considered Behavioral Health Integration services, or Collaborative Care Management (“BHI”). My healthcare provider and/or PursueCare staff has explained to me that they are the billing practitioner for the services that are performed by PursueCare health providers, but that in some cases where BHI is required or beneficial to my treatment, cost sharing may apply for both face-to-face and non-face-to-face services that are provided to me. This may include receiving bills for services which I am personally responsible for that come from consultation or services performed by a third-party health provider through BHI. Additionally, PursueCare may bill my insurance for BHI.

    I understand that in all such instances of BHI, PursueCare will only share information necessary for my health care and will limit the health information shared to that which is permissible by law. In circumstances where consultation falls outside of the ordinary BHI described in this section (such as when transferring your care to another treatment provider who is not affiliated with PursueCare), we will always ask for your express written permission.

    Delegation

    I may 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.

    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.

    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 care@pursuecare.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 care@pursuecare.com. Patients are responsible for the timely payments of all balances on their accounts.

    Insurance Authorization

    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.

    Self-Pay Policy and Credit Card Authorization

    Patients paying “out-of-pocket” for treatment, including co-payments, co-insurance, and deductibles, as well as charges for services not covered by insurance, must pay in full at the time of service. Payment is accepted via most major credit cards.

    By providing my credit card information, whether electronically through PursueCare’s secure patient care application, a third-party payment portal, or to PursueCare personnel, and by receiving telehealth services that are billable to me, I (i) authorize PursueCare to charge my credit card for any and all unpaid amounts that PursueCare or my insurer determines are my responsibility, and (ii) I agree to pay all amounts charged pursuant to this consent and authorization in accordance with the issuing bank cardholder agreement. I agree that PursueCare may charge my credit card for such amounts at the end of my telehealth visit or at a later date.

    I will be billed for all unpaid balances deemed by PursueCare or my insurer to be my responsibility and agree to pay such amounts in full. PursueCare may at its sole discretion charge late fees of 1.5% per month on unpaid balances starting 30 days after the first statement is mailed to me, as well as a $30 fee for returned checks. Delinquent accounts may be turned over to a collection agency and may be subject to collection and/or legal fees. I understand that PursueCare reserves the right to deny non-emergency services if my account is delinquent.

    Medicare/Medicaid Patient

    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/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.

    • “Treatment” means the provision, coordination, or management of your health care, including consultations between health care providers, including with primary care, hospital, emergency department, pain clinic, skilled nursing, assisted living, short-term rehabilitation, addiction treatment clinic, and other providers, relating to your care and referrals for addiction treatment and behavioral health care from one health care provider to another. For example, an attending physician at a hospital where you were treated for acute symptoms of Substance Use Disorder may need to know if you have a psychiatric disorder or are taking psychotropic medications because such disorders or medications may have disease-disease or drug-disease interactions with illicit substances you are taking, or with prescribed medications for Medication-Assisted-Treatment (“MAT”). In addition, the physician or other provider may need to contact another provider for purposes of treating a physical ailment or condition when our providers are not able to provide such care.
    • “Payment” means the activities we undertake to obtain reimbursement for the health care provided to you, including billing, claims management, determinations of eligibility and coverage, collections, case management, and other utilization review activities. For example, we may need to provide PHI to your insurance carrier or a party financially responsible for your care in order to determine whether the proposed course of treatment will be covered, to determine appropriate reimbursement, or to obtain payment. Federal or state law may require us to obtain a written release from you prior to disclosing certain specially protected PHI for payment purposes, and we will ask you to sign a release when necessary under applicable law.
    • “Health Care Operations” means the support functions for our practice and providers, related to referral, facilitating the telemedicine connection and visit, care coordination, compliance reviews, compliance programs, treatment and payment, quality assurance activities, receiving and responding to patient comments and complaints, provider training, audits, business planning, development, management, legal, and administrative activities. For example, we may use your PHI to evaluate the performance of our provider staff when caring for you. We may also combine PHI about many patients to make clinical qualitative review decisions or decide what additional services we should offer, what services are not needed, and whether certain treatments are effective. We may also disclose PHI for review and educational purposes. In addition, we may remove, or de-identify, information that identifies you so that others can use the de-identified information to study health care, conduct research, collect population health data, and determine methods for improved health care delivery without learning who you are.

    OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

    We may also use your PHI in the following ways:

    • To provide appointment reminders and schedule your availability with partner clinics, labs, and toxicology screening collection sites for your treatment.
    • To tell you about or recommend possible treatment alternatives or other health-related benefits and services that may be of interest to you.
    • To tell you about or recommend addiction recovery pharmacy services from our pharmacy, CompreCare Rx, which is Our wholly owned subsidiary company.
    • To your family, personal representative, power of attorney, guardian, emergency contact, or any other individual identified by you to the extent directly related to such person’s involvement in your care or the payment for your care. We may use or disclose your PHI to notify, or assist in the notification of, a family member, a personal representative, or another person responsible for your care, of your general condition, an emergency, or death. If you are available, we will give you an opportunity to object to these disclosures, and we will not make these disclosures if you object. If you are not available, incapacitated or unable to make informed consent decisions about your health care we will determine whether a disclosure to your family or personal representative is permitted or required by law, in your best interests, taking into account the circumstances, and act based upon our professional judgment.
    • When permitted by law, we may coordinate our uses and disclosures of PHI with public or private entities authorized by law or by charter to assist in disaster relief efforts.
    • We will allow your family and friends to act on your behalf to pick-up filled prescriptions and similar forms of PHI, when we determine, in our professional judgment, that it is in your best interest to make such disclosures, and in compliance with applicable state laws.
    • We may use or disclose your PHI for research purposes, subject to the requirements of applicable law. For example, a research project may involve comparisons of the health and recovery of all patients who received a particular medication. All research projects are subject to a special approval process which balances research needs with a patient’s need for privacy. When required, we will obtain a written authorization from you prior to using your PHI for research.
    • In certain cases, we will provide your information to contractors, agents and other parties who need the information in order to perform a service for us (“Business Associates”), including, without limitation, obtaining payment for health care services, technology services providers, or carrying out other business operations. In those situations, PHI will be provided to those contractors, agents and other parties as is needed to perform their contracted tasks. Business Associates are required to enter into an agreement maintaining the privacy of the protected health information released to them under certain terms and conditions required of them by state and federal law.
    • We may share your information with an insurance company, law firm or risk management organization in order to maintain professional advice about how to manage risk and legal liability, including insurance or legal claims. However, in these situations, we require third parties to provide us with assurances that they will safeguard your information under terms and conditions required by applicable state and federal law.
    • We will use or disclose PHI about you when required to do so by applicable law, only to the extent necessary to meet such a requirement.
    • In accordance with applicable law, we may disclose your PHI to your employer if we are retained to conduct an evaluation of whether you have a work-related illness or injury. You will be notified of these disclosures by your employer or the provider as required by applicable law.
    • Incidental uses and disclosures of PHI sometimes occur and are not considered to be a violation of your rights. Incidental uses and disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and cannot be reasonably prevented.

    SPECIAL SITUATIONS

    Subject to the requirements of applicable law, we will make the following uses and disclosures of your PHI:

    • Involuntary patients: Information regarding patients who are being treated involuntarily, pursuant to law, will be shared with other treatment providers, legal entities, third party payors and others, as necessary to provide the care and management coordination needed in compliance with state and federal law.
    • Emergencies: In life threatening emergencies, we will disclose information necessary to avoid serious harm or death.
    • Organ and Tissue Donation. If you are an organ donor, we may release PHI to organizations that handle organ procurement or transplantation as necessary to facilitate organ or tissue donation and transplantation.
    • Military and Veterans. If you are a member of the Armed Forces, we may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.
    • Worker’s Compensation. We may release PHI about you for programs that provide benefits for work-related injuries or illnesses.
    • Public Health Activities. We may disclose PHI about you for public health activities, including disclosures:
      • to prevent or control disease, injury or disability;
      • to report births and deaths;
      • to report child abuse or neglect;
      • to persons subject to the jurisdiction of the Food and Drug Administration (FDA) for activities related to the quality, safety, or effectiveness of FDA-regulated products or services and to report reactions to medications or problems with products;
      • to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
      • to notify the appropriate government authority if we believe that an adult patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if the patient agrees or when required or authorized by law.
    • Health Oversight Activities: We may disclose PHI to federal or state agencies that oversee our activities (e.g., providing health care, seeking payment, integrity agreements, audits, and civil rights).
    • Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, or a guardianship proceeding, we may disclose PHI subject to certain limitations and only to the extent permissible by law.
    • Law Enforcement: We may release PHI if asked to do so by a law enforcement official:
      • In response to a court order, warrant, summons or similar process;
      • To identify or locate a suspect, fugitive, material witness, or missing person;
      • About the victim of a crime under certain limited circumstances;
      • About a death we believe may be the result of criminal conduct;
      • About criminal conduct on our premises; or
      • In emergency circumstances, to report a crime, the location of the crime or the victims, or the identity, description or location of the person who committed the crime.
    • Coroners, Medical Examiners and Funeral Directors: We may release PHI to a coroner or medical examiner. We may also release PHI about patients to funeral directors as necessary to carry out their duties.
    • National Security and Intelligence Activities: We may release PHI about you to authorized federal officials for intelligence, counterintelligence, other national security activities authorized by law or to authorized federal officials so they may provide protection to the President or foreign heads of state.
    • If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release PHI about you to the correctional institution or law enforcement official. This release would be necessary (1) to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution or law enforcement.
    • Serious Threats. As permitted by applicable law and standards of ethical conduct, we may use and disclose PHI if we, in good faith, believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public or is necessary for law enforcement authorities to identify or apprehend an individual.

    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:

    • The patient consents in writing;
    • The disclosure is allowed by a court order; or
    • The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

    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.

    BEHAVIORAL HEALTH INTEGRATION AND COLLABORATIVE CARE MANAGEMENT

    I understand that my PursueCare health provider and/or supporting and coordinating PursueCare staff may consult with relevant specialists related to my care, including psychiatric consultants, pharmacy professional staff, laboratories, primary care or referring health providers, and health care personnel who may collaborate or affiliate with PursueCare for my overall health care needs, and/or referred me to PursueCare’s health services. These services are broadly considered Behavioral Health Integration services, or Collaborative Care Management (“BHI”). My healthcare provider and/or PursueCare staff has explained to me that they are the billing practitioner for the services that are performed by PursueCare health providers, but that in some cases where BHI is required or beneficial to my treatment, cost sharing may apply for both face-to-face and non-face-to-face services that are provided to me. This may include receiving bills for services which I am personally responsible for that come from consultation or services performed by a third-party health provider through BHI. Additionally, PursueCare may bill my insurance for BHI.

    I understand that in all such instances of BHI, PursueCare will only share information necessary for my health care and will limit the health information shared to that which is permissible by law. In circumstances where consultation falls outside of the ordinary BHI described in this section (such as when transferring your care to another treatment provider who is not affiliated with PursueCare), we will always ask for your express written permission.

    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:

    • of psychotherapy notes (where appropriate, as described above);
    • for marketing purposes; and that constitute a sale of PHI under the Privacy Rule. Other uses and disclosures of PHI not covered by this notice or the laws that apply to us will be made only with your written authorization. You have the right to revoke that authorization at any time, provided that the revocation is in writing, except to the extent that we already have taken action in reliance on your authorization.

    YOUR RIGHTS

    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:

    • psychotherapy notes, (i.e., notes that have been recorded by a mental health professional documenting counseling/therapy sessions and have been separated from the rest of your medical record);
    • information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding;
    • PHI involving laboratory tests when your access is restricted by law;
    • if you are a prison inmate, and access would jeopardize your health, safety, security, custody, or rehabilitation or that of other inmates, any officer, employee, or other person at the correctional institution or person responsible for transporting you;
    • if we obtained or created PHI as part of a research study, your access to the PHI may be restricted for as long as the research is in progress, provided that you agreed to the temporary denial of access when consenting to participate in the research;
    • PHI contained in records kept by a federal agency or contractor when your access is restricted by law; and
    • PHI obtained from someone other than us under a promise of confidentiality when the access requested would be reasonably likely to reveal the source of the information.

    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:

    • was not created by us, unless you provide a reasonable basis to believe that the originator of PHI is no longer available to act on the requested amendment;
    • is not part of your medical or billing records or other records used to make decisions about you;
    • is not available for inspection as set forth above; or
    • is accurate and complete.

    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 carry out treatment, payment and health care operations as provided above;
    • incidental to a use or disclosure otherwise permitted or required by applicable law;
    • pursuant to your written authorization;
    • to persons involved in your care or for other notification purposes as provided by law;
    • for national security or intelligence purposes as provided by law;
    • to correctional institutions or law enforcement officials as provided by law;
    • as part of a limited data set as provided by law.

    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/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.

    COMPLAINTS

    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.

    CONTACT PERSON

    If you have any questions or would like further information about this Notice, please contact the Privacy Officer at 860.215.2295.



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