CONSENT TO TREAT

 

1. I voluntarily consent to medical care recommended by the clinician including x-rays, heart tracings, medications, and/or routine laboratory testing (including human immunodeficiency virus infection, hepatitis, or any other blood-borne infectious disease if ordered by a clinician for diagnostic purposes). 

2. I authorize the clinic to release medical/behavioral health information to insurance carriers for the purposes of filing insurance claims related to my/his/her medical care. 

3. I agree that insurance (if applicable) will be billed for services and I (patient, parent or guardian of the patient) am responsible for any charges not paid or denied by the insurance company. 

4. I understand that even if you have a copy of my Advance Directive or Living Will that clinic staff will attempt to stabilize me and transfer me to an acute care hospital for further evaluation and treatment. 

5. I have received the Patient Packet containing ARcare’s Notice of Privacy Practices and my rights about my medical information as a patient of ARcare.

TELEMEDICINE CONSENT 

1. I authorize ARcare/MississippiCare/KentuckyCare to allow me/the patient to participate in a telemedicine/Virtual Care (videoconferencing) service with ARcare. This consent applies to both Physical and Behavioral Health Services. a. If Behavioral Health Services is indicated or requested: I understand that Tele-behavioral health services are completely voluntary and that I can choose not to do or not to answer questions at any time. I understand that I will be assigned one therapist and will only see that that therapist for my behavioral health care via tele-behavioral health services in ensuring continuity of care. I understand that I will be asked to create a safety plan with my therapist in case of an emergency. I understand that if there's an emergency during a Tele-behavioral health session, my therapist will call emergency services and my emergency contacts. 2. The type of service to be provided via telemedicine is Acute Care Services. 3. I understand that this service is not the same as a direct patient/healthcare provider visit, because I/the patient will not be in the same room as the healthcare provider performing the service. I understand that parts of my/the patient’s care and treatment which require physical tests or examinations may be conducted by the clinical staff at my/the patient’s location under the direction of the telemedicine healthcare provider. 4. My/the patient’s physician has fully explained to me the nature and purpose of the videoconferencing technology and has also informed me of expected risks, benefits and complications (from known and unknown causes), attendant discomforts and risks that may arise during the telemedicine session, as well as possible alternatives to the proposed sessions, including visits with a physician in-person. The attendant risks of not using telemedicine sessions have also been discussed. I have been given an opportunity to ask questions, and all my questions have been answered fully and satisfactorily. 5. I understand that there are potential risks to the use of this technology, including but not limited to interruptions, unauthorized access by third parties, and technical difficulties. I am aware that either my/the patient’s healthcare provider or I can discontinue the telemedicine service if we believe that the videoconferencing connections are not adequate for the situation. 6. I understand that the telemedicine session will not be audio or video recorded at any time. 7. I agree to permit my/the patient’s healthcare information to be shared with other individuals for the purpose of scheduling and billing. I agree to permit individuals other than my/the patient’s healthcare provider and the remote healthcare provider to be present during my/the patient’s telemedicine service to operate the video equipment. I further understand that I will be informed of their presence during the telemedicine services. I acknowledge that if safety concerns mandate additional persons to be present, then my/guardian permission may not be needed. 8. I acknowledge that I have the right to request the following: a. The omission of specific details of my/the patient’s medical history/physical examination that is personally sensitive, or b. Termination of the service at any time. 9. When the telemedicine service is being used during an emergency, I understand that it is the responsibility of the telemedicine provider to advise my/the patient’s local healthcare provider regarding necessary care and treatment. 10. It is the responsibility of the telemedicine provider to conclude the service upon the termination of the videoconference connection. 11. I/the patient understand(s) that my/the patient’s insurance will be billed by both the local healthcare provider and the telemedicine healthcare provider for telemedicine services. I/the patient understand(s) that if my insurance does not cover telemedicine services I/the patient will be billed directly by the telemedicine healthcare provider for the provision of telemedicine services. 12. My/the patient’s consent to participate in this telemedicine service for the duration of the specific service identified above, or until I revoke my consent in writing. 13. I/the patient agree that there have been no guarantees or assurances made about the results of this service. 14. I confirm that I have read and fully understand both the above and the Telemedicine: What to Expect Form provided.

CONSENT TO OBTAIN MEDICAL HISTORY

Our medical practice has adopted an electronic medical record system in order to improve the quality of our services. This system also allows us to collect and review your “medication history.” A medication history is a list of prescription medicines that we or other doctors have recently prescribed for you. This list is collected from a variety of sources, including your pharmacy and your health insurer. An accurate medication history is very important in helping us treat you properly and in avoiding potentially dangerous drug interactions. By signing this consent form you give us permission to collect, and give your pharmacy and your health plan permission to disclose information about your prescriptions that have been filled at any pharmacy or covered by any health insurance plan. This includes prescription medicines to treat AIDS/HIV and medicines used to treat mental health conditions, such as depression. This information will become part of your medical record. The medication history is a useful guide, but it may not be completely accurate. Some pharmacies do not make drug history available to us, and the drug history from your health plan might not include drugs that you purchased without using your health insurance. Your medication history might not include over the counter medicines, supplements or herbal remedies. It is still very important for us to take the time to discuss everything you are taking, and for you to point out to us any errors in your medication history. By electronically signing this document above, I give permission for you to obtain my (or adult consent for the patient) medication history from my pharmacy, my health plans, and my other healthcare providers.

**I understand that I can revoke this release of medical information at any time by completing a new form.

HIPAA PRIVACY PRACTICES CONSENT FORM

We are committed to providing security for patient privacy and confidentiality.  We collect, use, and disclose personal health information only when allowed by state and federal laws and your personal authorization. This may include the collection of other sources of information available, such as medication and prescription history and verification of insurance eligibility.  

We also understand you may have family members or significant people in your life who you may want to have access to certain information contained in your medical record.  Without your written consent, we cannot release any information to anyone except for purposes outlined in the HIPAA privacy act. Please note that we use an automated phone system to remind you of appointments as well as offer patients the opportunity to complete a survey about their visit. 

I give permission for those (employees, students, volunteers, contractors, etc.) acting on behalf of the organization to share my protected health information (PHI) with the following specific person(s): (If no other person is authorized to receive your PHI, type N/A in the spaces below.)

Information to be released:

[1] Copy of complete health record
[2] History and physical
[3] Test results
[4] Mental health records
[5] Reproductive health records                             
[6] Other:  (Use text space to indicate information to be released.)

 A.     OUR COMMITMENT TO YOUR PRIVACY

Our practice is dedicated to maintaining the privacy of your individually identifiable health information as protected by law, including the Health Information Portability and Accountability Act (HIPAA). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your Personally Identifiable Information (PII). By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time. We realize that these laws are complicated, but we must provide you with the following important information:

How we may use and disclose your PII

Your privacy rights in your PII

Our obligations concerning the use and disclosure of your PII

 This notice describes ARcare’s/KentuckyCare’s/MississippiCare’s privacy practices and that of:

Ø   All of our doctors, nurses, and other health care professionals authorized to enter information about you into the medical chart.

Ø   All of our departments including medical records, billing, and insurance departments.

Ø   All of our employees, staff, volunteers and other personnel who work for us or on our behalf.

Ø   In addition these sites and locations may share medical information with each other for treatment, payment or operation purposes described in this notice.

 The terms of this notice apply to all records containing your PII that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and doe any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

 B.      IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE:                           

C. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION (PII)  IN THE FOLLOWING WAYS:

 1. Treatment. Our practice may use your PII to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PII in order to write a prescription for you, or we might disclose your PII to a pharmacy when we order a prescription for you. Many of the people who work for our practice- including, but not limited to, our doctors and nurses- may use or disclose your PII in order to treat you or to assist others in your treatment. Additionally, we may disclose your PII to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PII to other health care provides for a purpose related to your treatment.

2. Payment. Our practice may use and disclose your PII in order to bill and collect payments for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits) and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PII to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PII to bill you directly for services and items. We may disclose your PII to other health care providers and entities to assist in their billing and collection efforts. You have the right to restrict disclosures of protected health information to health plans if you have paid for services out of pocket in full.

3. Health Care Operations. Our practice may use and disclose your PII to operate our business. As examples of the ways in which we may use and disclose your information for our operations, out practice may use your PII to evaluate the quality of care you received from us or to conduct cost-management and business planning activities for our practice. We may disclose your PII to other health care providers and entities to assist in their health care operations. We may make your health information available electronically through an electronic health information exchange to other health care providers and healthcare plans that request your information for their treatment and payment purposes. Participation in electronic health information exchange also lets us see their information about you for our treatment and payment purposes.

4.  Appointment Reminders. Our practice may use and disclose your PII to contact you and remind you of an appointment.

5. Treatment Options. Our practice may use and disclose your PII to inform you of potential treatment options or alternatives.

6. Health-Related Benefits and Services. Our practice may use and disclose your PII to inform you of health-related benefits or services that may be of interest to you.

7. Fundraising. We may contact you to raise funds for our organization.

8. Release of Information to Family/ Friends. Our practice may release your PII to a friend or family member that is involved in your care or assists in taking care of your, For example, a parent or guardian may ask a babysitter to take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this child’s medical information.

9. Disclose Required by Law. Our practice will use and disclose your PII when we are required to do so by federal, state, or local law.

D.  USE AND DISCLOSURE OF YOUR PII  IN CERTAIN SPECIAL CIRCUMSTANCES

The following categories describe unique scenarios in which we may use or disclose your personally identifiable health information.

1. Public Health Risks. Our practice may disclose your PII to public health authorities that are authorized by law to collect information for the purpose of:

Maintaining vital records, such as births and deaths

Reporting child abuse or neglect

Preventing or controlling disease, injury or disability

Notifying a person regarding potential exposure to a communicable disease

Notifying a person about a potential risk for spreading or contracting a disease or condition

Reporting reactions to drugs or problems with products or devices

Notifying individuals if a product or device they may be using has been recalled

Notifying appropriate government agencies and authorities regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information.

Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2. Health Oversight Activities. Our practice may disclose your PII to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and Similar Proceedings. Our practice may use and disclose your PII in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your PII in response to a discovery request, subpoena, or other lawful processes by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party had requested.

4. Law Enforcement. We may release PII if asked to do so by law enforcement official:

Regarding a crime victim in a certain situation, id we are unable to obtain the person’s agreement

Concerning a death, we believe had resulted from criminal conduct

Regarding criminal conduct at our offices

In response to a warrant, summons, court order, subpoena or similar legal process

To identify/locate a suspect, material witness, fugitive or missing person

In an emergency, to report a crime (including the location or victim (s) of the crime, or the description, identity or location of the perpetrator)

5. Deceased Patients. Our practice may release PII to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their job.

6. Organ and Tissue Donation. Our practice may release your PII to organizations or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order or tissue donation and transplantation if you are an organ donor.

7. Research. Our practice may use and disclose your PII for research purposes in certain limited circumstances. We will obtain your written authorization to use your PII for research purpose except when Internal or Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and discloser; (B) and adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (C) adequate written assurance that the PII will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the reach study, or for other research for which the use of discloser would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without access to and use of the PII.

8. Serious Threats to Health or Safety. Our practice may use and disclose your PII when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

9. Military. Our practice may disclose your PII if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

10. National Security. Our practice may disclose your PII to federal officials for intelligence and national security activities authorized by law. We also may disclose your PII to federal officials in order to protect the president, other officials or foreign heads of state, or to conduct investigations..

11. Workers’ Compensation. Our practice may release your PII for workers’ compensation and similar programs.

12. Coroner, Medical Examiner, Funeral Director. We may release Health Information to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death.  We also may release Health Information to funeral directors as necessary for their duties.

13. Business Associates.  We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  For example, we may use another company to perform billing services on our behalf.  All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

14. Inmates or Individuals in Custody.  If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official.  This release would be if necessary: (a) for the institution to provide you with health care; (b) to protect your health and safety or the health and safety of others; or (c) the safety and security of the correctional institution.

E.  YOUR RIGHTS REGARDING YOUR PII

You have the following rights regarding the PII that we maintain about you:

1. Confidential Communications. You have the right to request that our practice communicates with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work, in order to request a type of confidential communication, you must make a written request to the Privacy Officer specifying the requested method of contact or the location where you wish to be contacted, our practice will accommodate reasonable request. You do not need to give a reason for your request.

2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your PII for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PII to other certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PII, you must make your request in writing to the Privacy Officer. Your request must describe in a clear and concise fashion:

a) the information you wish restricted;

b) whether you are requesting to limit our practice’s use, disclosure or both; and

c) to whom you want the limits to apply

3. Inspection and copies. You have the right to inspect and obtain a copy (paper or electronic) of the PII that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to the Privacy Officer in order to inspect and/or obtain a copy of your PII. Our practice may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or four our practice. To request an amendment, your request must be made in writing and submitted to the Privacy Officer. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion (a) accurate and complete; (b) not part of the PII kept by or for the practice; (c) not part of the PII which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures”. An “accounting of disclosers” is a list of certain not-routine disclosers our practice has made of your PII for non-treatment, not a payment or non-operations purposes. The use of your PII as part of the routine patient care in our practice is not required to be documented. For example, the doctor was sharing information with the nurse; or the billing department using your information to file your insurance claim. Also, we are not required to document disclosures made pursuant to an authorization signed by you. To obtain an accounting of disclosures, you must submit your request in writing to the Privacy Officer. All requests for an accounting of disclosure must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6. Rights to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact the Privacy Officer.

7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint without practice, contact the Privacy Officer.

We urge you to file your complaint with us first and give us the opportunity to address your concerns. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses/disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PII may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PII for the reasons described in the authorization. Please note, we are required to retain records of your care.

9. Right to Notice in the event of a Breach. Our practice will notify you in the event there is a breach of your PII.

 For Complete details about how we may use your PII, please visit: 

 https://www.arcare.net/PrivacyPolicy

https://www.kentuckycare.net/PrivacyPolicy

https://www.mississippicare.net/PrivacyPolicy

 NOTICE REGARDING WELLNESS PROGRAM

ARcare “A HEALTHIER YOU” is a voluntary wellness program available to all employees who are covered by the ARcare Health Plan in 2025. Thank you to everyone who participated last year. These wellness visits help identify chronic diseases early. Early detection helps lead to better outcomes. This helps everyone’s insurance cost stay consistent.

The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. 

If you choose to participate in the “A HEALTHIER YOU” wellness program you will be asked to complete a voluntary physical exam at an ARcare Medical Clinic (including KentuckyCare and MississippiCare locations), and a medical questionnaire for such office visit that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You will also be asked to complete a biometric screening at this visit, which will include, but may not be limited to, blood tests for diabetes, blood counts, thyroid function, hepatitis, and cholesterol.

You are not required to complete the office visit or to participate in the blood test or other medical examinations. However, eligible employees who choose to participate in the wellness program will receive an incentive of a $50 bonus for completing the office exam (including the biometric screening). Although you are not required to complete the exam or medical questionnaire or participate in the biometric screening, only employees who do so will receive an e-gift card.

In order to participate, you will need to complete your office exam with an ARcare/KentuckyCare/MississippiCare Medical Clinic between April 1, 2025 and June 30, 2025, and identify yourself as an employee currently covered by the ARcare Health Plan. You may complete this exam during ARcare work hours. Once your exam is scheduled, you will receive a link (via secure e-mail) by which you may complete the medical questionnaire prior to the office visit. If you have any questions about completing the medical questionnaire or scheduling the visit, please call Breanna Walker at 501.501.2226.

The information from your office exam and the results from your biometric screening will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program, such as case management, closing gaps in care, and/or chronic disease management services. You also are encouraged to share your results or concerns with your own doctor.

Employee spouses covered by the ARcare Health Plan may also voluntarily participate in the wellness program by completing a physical exam and biometric screening at an ARcare/KentuckyCare/MississippiCare Medical Clinic. Covered spouses who participate in the wellness program will not be eligible for the wellness incentive.

PROTECTIONS FROM DISCLOSURE
OF MEDICAL INFORMATION

We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and the ARcare Health Plan may use aggregate information it collects to design a program based on identified health risks in the workplace, the ARcare “A HEALTHIER YOU” wellness program and the ARcare Health Plan will never disclose any of your personal information either publicly or to the employer, except as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment.

Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The individuals who will receive your personally identifiable health information are necessary ARcare (in its capacity as medical provider) and BlueAdvantage Administrators’ staff,  as necessary to facilitate the availability of other programs and services and to process claims under the Plan. Please be aware that you may be contacted by such medical staff following your exam, in order to make you aware of your results and offer additional medical resources that may be of interest to you and which are strictly voluntary.

In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately.

You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate.

If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact Dave Ferguson at david.ferguson@arcare.net.

 

 

By participating in the voluntary “A Healthier You” wellness program, I consent to being contacted by the wellness coordinator and medical staff as may be necessary for any follow-up to my wellness exam and biometric testing results.