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THE CARE CLINIC | CARE CLINIC INFUSIONS

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Treatment Agreement & Controlled Substance Informed Consent

• I understand I may be prescribed a controlled substance and have reviewed the risks and benefits of this medication, including in-person with my doctor/provider and online at www.careclinicmd.com. Both patients and health care providers have responsibility for the appropriate and safe use of controlled substances.
• Risks of the particular medication(s) you are being prescribed or may be prescribed are listed online at www.careclinicmd.com. I have reviewed this and questions have been answered to my satisfaction.
• Goals of Treatment: The primary goal of utilizing this medication is to improve my ability to engage in work, home, social and physical activities and ultimately improve my quality of life. This agreement serves as a plan of care to achieve these goals safely and effectively. If these goals are not achieved alternative plans will need to be discussed with my provider. It is not expected that 100% of my symptoms will be relieved with medication. I understand that my provider is under no obligation to prescribe these medications to me, and that my provider reserves the right to discontinue these medications at any time. If it appears to my provider that there are no clear benefits to my daily function or quality of life from the controlled medication, or if I develop rapid tolerance or loss of effect from this treatment, I will be gradually tapered or the medication may be discontinued.
• I understand the frequency of visits will vary (1-4weeks) depending on my history and compliance. I understand that if I miss appointments then I will return to more frequent visits until assurance in my treatment is reestablished. I must call 24 hours prior to canceling an appointment. If I miss an appointment without contacting my provider: I may be asked to return to more frequent visits, may not have my medication refilled until I am seen again, and I may be discharged.
• I understand that if I am not seen in the office as prescribed by my provider, I will be unable to obtain my prescriptions and I may be discharged from the program.
• I agree to take my medication as prescribed at the dosage determined by my providers; and not to allow anyone else to take medications prescribed for me.
• I agree not to take any other controlled substances other than that which is prescribed to me by my Care Clinic provider without prior permission from my provider. I understand that overdose deaths have occurred when patients combine certain medications (particularly when medications like Librium®, Valium®, Xanax®, Klonopin® or other benzodiazepines are combined with narcotics.
• I understand that combining illegal substances with prescribed medication increases my risk of breathing difficulties, heart disorders, and sudden death. If I do so, I may be discharged from the practice.
• I understand that the Care Clinic providers will not be available to prescribe medication during evenings and some weekends. It is my responsibility to call my provider at least 2(two) business days in advance of running out of medications.
• It has been explained to me and I understand that the medication(s) I am being prescribed are controlled substances and can produce physical dependency in some patients.
• I understand that the fee for our servies ONLY covers our visit fee. This fee DOES NOT include the cost of medications, or any other services provided.
• I will submit a urine specimen for drug screen (narcotics, cocaine, amphetamine, PCP, alcohol, benzodiazepine, and others) upon my provider’s request at a minimum of every 4 weeks and as often as directed. My provider may ask that a clinical staff member observe me providing the appropriate urine specimen. If my drug screen indicates the presence of illegal/ inappropriate substances, or tampering or misuse of their urine, I may be discharged.
• I understand that I will be required at any time with short notice to bring in my medication for my provider to inspect, count and/or destroy. If I do not show or have the appropriate number of pills, I may be discharged. I may never dispose of my medications myself without a staff member as a witness.
• I allow my provider to communicate with other providers regarding my medical care, consistent with HIPAA guidelines. Treatment disclosure may include, but is not limited to, discussing my medications with the pharmacist. I understand that records released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may contain confidential information about communicable diseases including HIV (AIDS) or related illnesses.
• I give consent to retrieve prescription history when a request is triggered.
• I give consent to retrieve my prescription drug history on the statewide and nationwide prescription drug monitoring program.
• I will not sell, share, or trade my medication with anyone. It is understood that if caught doing so, I will be discharged without the chance to be readmitted.
• I will safeguard my written prescription and medication from loss, damage or theft. We recommend a lock box especially for those with children. Lost, stolen or damaged prescriptions/medications may be replaced at the provider’s discretion. If replaced, no prior authorization will be completed and you will be responsible for any prescription costs in such cases.
• I will never alter a prescription in ANY way. I understand this is a felony, punishable by incarceration.
• I authorize my provider and my pharmacy to cooperate fully with any city, state, or federal law enforcement agency, including the State’s Board of Pharmacy and the DEA, in the investigation of any possible misuse, prescription forgery, sale or any other diversion of my medication.
• I will allow my provider to receive information from any pharmacy I have used.
• I understand that rude or disrespectful treatment of staff is not tolerated and may result in my discharge. (Ex: using profanity, raising my voice, making vulgar or inappropriate comments).
• [For women of childbearing potential] I agree to tell my physician if I become pregnant or even think I may be pregnant.
• I understand that I must provide a viable contact number at all times (and will update the office of any changes) or my provider may not prescribe medications.
• I understand the commitment to our programs  and the many appointments, therefore transportation cannot be an issue or a reason for short notice cancelations or no show appointments.
• I understand that my prescription will need to be filled immediately following my appointment while our staff is still available to take care of any questions or issues at the pharmacy.
• I understand that a copy of this agreement may be provided to the ER, pharmacy or other providers involved with my care.
• SHOULD I CHOOSE TO USE THIS MEDICATION IN ANY WAY OTHER THAN THAT PRESCRIBED, I AGREE THAT MY PROVIDER WILL NOT BE RESPONSIBLE FOR ANY DAMAGE TO MY HEALTH, OTHER PERSONS, OR PROPERTY.
• I UNDERSTAND THAT ANY VIOLATION OF THIS AGREEMENT MAY RESULT IN THE IMMEDIATE TERMINATION OF MEDICATIONS PRESCRIPTIONS, AND POSSIBLY TERMINATION OF ALL SERVICES FROM MY CONTROLLED SUBSTANCE PROVIDER. IF THE VIOLATION INVOLVES SUSPECTED ILLEGAL ACTIVITY, I UNDERSTAND THAT THE INCIDENT MAY ALSO BE REPORTED TO OTHER HEALTHCARE PROVIDERS, PHARMACIES, AND OTHER LEGAL AUTHORITIES, AS REQUIRED BY LAW.
• Informed consent: This document has been reviewed with me and my questions have been answered. My signature below verifies I understand the information.

PATIENT CONSENT TO TREATMENT

I hereby consent to psychiatric and/or medical evaluation and treatment with AroraMD LLC, DBA CARE Clinic and/or his associates and authorize AroraMD LLC, DBA CARE Clinic, its employees and agents to administer treatment. This in no way constitutes a warranty or guarantee that my present condition will be cured. AroraMD LLC, DBA CARE Clinic, its staff and employees will provide me with the best possible care available but no assurance of cure is to be assumed.

I also consent to treatment agreeing to the payment and refund policy with the understanding that the providers are out of network and/or not contracted with my insurance company and therefore the services provided will not be covered and reimbursable services. Therefore I am responsible for the entire payment due at the time of service. 

I sign this willingly and voluntarily in full understanding of the above, and in so doing I release AroraMD LLC, DBA CARE Clinic its directors and officers, staff employees, agents and physicians from any and all liability which may arise from this action, whether or not foreseen at present.

PATIENT CONSENT TO PAYMENTS

I authorize Aroramd LLC, dba Care Clinic (“The Care Clinic”), to save my card on file and to automatically charge the debit or credit card below, the amount due on my account and/or to pay the premium I owe, under my Insurance contract, following appointments with providers, including, but not limited to, any deductibles, copay and coinsurance charges and no-show, or same day cancellation charges. I understand and agree that payment is due after each visit, and The Care Clinic will charge my card or bank account for the patient responsibility.  

I agree that all people or companies (third parties) who pay any part of your The Care Clinic bill shall pay these amounts directly to The Care Clinic. I understand that you must pay The Care Clinic any costs not paid by your insurance or other third parties, including, but not limited to, any deductibles, copay and coinsurance charges, no-show, or same day cancellation charges, and I agree to authorize The Care Clinic to charge my debit or credit card for all delinquent amounts owed to The Care Clinic, unless state or federal regulations do not allow this.

I understand that The Care Clinic will initiate transfers/charges according to this authorization and agreed upon appointment charges not to exceed the amount on my balance. If I notice a discrepancy in the amount charged to the amount on the balance, I can contact Care Clinic to determine the appropriate charge; a refund can be issued, or the balance could be applied as a credit to future visits.

I authorize these automatic payments to continue until I notify The Care Clinic, in writing, to cancel it within a reasonable amount of time. I may contact The Care Clinic by phone or email to request that future payments be changed or discontinued. The Care Clinic will not make charges to my credit or debit card after I have cancelled.

I understand that by entering my information below, I acknowledge the terms set forth in this agreement.

By accepting this Agreement you indicate that you have read and understood this Agreement, and that you agree to abide by its terms. Further, you certify that if you are accepting this Agreement as a personal representative of the insured patient, you have legal authority to provide consent for the treatment of the insured patient.

Refund Policy:

No refunds shall be issued after service has been provided. I understand I am waiving my right to dispute this charge with my bank for claims of services not received or other similar claim of non-service.

NOTICE OF PRIVACY

Please be advised that all information regarding our patients remains confidential. We do not disclose any patient information without a signed authorization of release. Excluded are the following: 1) To show compliance with the privacy rule, to appropriate agency. 2) We will disclose medical information about you, when required by federal, state or local law. 3) In response to a court order, subpoena, warrant summons or similar process. 4) To report child abuse or neglect. 5) To prevent serious threat to your health and safety or the health and safety of others. 6) For health oversight activities with the patients treating physician. 7) To a coroner or medical examiner for identification, cause of death, or other duties authorized by law. Please be advised that under the Privacy Rule, patients have the federal right to access their own medical record, except Psychiatric Notes. The patient can authorize the release of Psychiatric Notes to other parties, such as attorneys, or other treating physicians. I understand that AroraMD LLC, DBA CARE Clinic will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.”

CONSENT TO CONTACT VIA EMAIL AND SMS TEXT

Patients in our practice may be contacted via email and/or text messaging to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information. If at any time I provide an email or text address at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/ information at that email or text address from the Practice.  I consent to receive text messages from the practice at my cell phone and any number forwarded or transferred to that number or emails to receive communication as stated above. I understand that this request to receive emails and text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. I further consent that if I do not agree to the above, but initiate email or text messaging contact with Dr. Arora or his staff, then that shall serve as my consent for Dr. Arora and his staff to communicate back to me via email or text message, including the transmission of any confidential information regarding my case, via email or text message. With this consent, I agree to not hold Dr. Arora nor any of his staff liable if there is a security breach or leak of any of my confidential information sent via email or text message in this aforementioned manner. I give my permission to release any medical or psychological information regarding my treatment to my insurance company via phone, fax, email or correspondence. This authorization will not be used for any purpose other than stated. I may revoke this authorization in writing at any time. I have read and understand the above consent form.

TELEMEDICINE CONSENT FORM

I authorize Care Clinic’s contracted providers to provide me with their observations and recommendations regarding my psychiatric condition and potential courses of action, using telemedicine. The use of telemedicine involves the electronic communication of my medical information. I understand that Care Clinic is a Telehealth Technology Provider based in Florida and its contracted providers will not perform an in-person physical examination during the telemedicine consult. They will rely solely on the information telecommunicated. I authorize the Care Clinic contracted provider to consult with any other physician specialists whom they may choose to involve in my case if necessary.

I authorize Care Clinic’s contracted providers to provide me with their observations and recommendations regarding my psychiatric condition and potential courses of action, using telemedicine. The use of telemedicine involves the electronic communication of my medical information. I understand that Care Clinic is a Telehealth Technology Provider based in Florida and its contracted providers will not perform an in-person physical examination during the telemedicine consult. They will rely solely on the information telecommunicated. I authorize the Care Clinic contracted provider to consult with any other physician specialists whom they may choose to involve in my case if necessary. 

I understand that I have the following rights with respect to the telemedicine services performed by Care Clinic: 1. Right to withdraw. I have the right to withhold or withdraw my consent to telemedicine at any time, without effecting my future right to health care or treatment and without risking the loss of my health coverage. 2. Confidentiality. The laws that protect the confidentiality of medical information apply to telemedicine, and no information or images from the telemedicine interaction which identify me will be disclosed to other parties without my consent, except as permitted by law. 

I understand that there are risks from telemedicine, including but not limited to: loss of records from failure of electronic equipment; power failure with loss of communication; and invasion of electronic records from outsiders (hackers). In addition, signs and symptoms that might be detected during an in person physical examination may not be detected through telemedicine. I understand that I have the option of seeing another physician on a face to face basis who could provide me with observations and recommendations.

I warrant that the Care Clinic provider/physician observations and recommendations are limited in scope and nature to the specific issues discussed during the telemedicine consult.

I am aware telemedicine visits will not go through my insurance and I am responsible for all the expenses related to my online consult.

My telemedicine consult is solely based on the information provided by me and in the absence of a physical evaluation. The providers of Care Clinic may not be aware of certain facts that may limit or affect their assessment or diagnosis of my condition and recommended treatment.

An online consult is not intended to replace a full medical face-to-face evaluation.

I have read and understand the information provided above. I agree and all my questions have been answered to my satisfaction. I consent to receiving the telemedicine services described above.

AUTHORIZATION TO PHOTOGRAPH OR VIDEO

This authorization or photocopy hereof, will authorize you to be photographed or video taping or audiotaping for treatment purposes related to your healthcare, professional activities, insurance claims, and patient education. I do hereby release Aroramd LLC dba Care Clinic, its agents and employees from all liability in connection with the above. I waive any right to inspect or approve the finished product or other copy that may be used in connection with the above. I hereby consent to the above, without expectation of remuneration to me now or in the future, and this shall be binding upon my heirs, personal representatives and assigns.

Buprenorphine (Suboxone/Subutex) Informed Consent and Treatment Agreement

• I understand the frequency of visits will vary (1-4weeks) depending on my abuse history and compliance. I understand that if I relapse or miss appointments then I will return to more frequent visits until assurance in my recovery is reestablished. I must call 24 hours prior to canceling an appointment. If I miss an appointment without contacting my provider: I may be asked to return to more frequent visits, may not have my medication refilled until I am seen again, and I may be discharged.
• I understand that if I am not seen in the office as prescribed by my provider, I will be unable to obtain my prescriptions and I may be discharged from the program.
• I agree to take Buprenorphine as prescribed at the dosage determined by my providers; and not to allow anyone else to take medications prescribed for me.
• I understand that I will be required to attend AA/NA meetings or other similar meetings focused on addiction and recovery and may be required to attend group therapy if my provider does not provide the therapy during my visit.
• I agree not to take any other controlled substances with Buprenorphine without prior permission from my provider. I understand that overdose deaths have occurred when patients have taken other medications (particularly medications like Librium®, Valium®, Xanax®, Klonopin® or other benzodiazepines) with Buprenorphine.
• I understand that combining illegal substances with prescribed medication increases my risk of breathing difficulties, heart disorders, and sudden death. If I do so, I may be discharged from the practice.
• I understand that the Buprenorphine providers will not be available to prescribe medication during evenings, some weekends. It is my responsibility to call my provider at least 2(two) business days in advance of running out of medications.
• It has been explained to me and I understand that Buprenorphine itself is an opiate drug, although a partial agonist, it can still produce physical dependency in non-opiate dependent patients.
• The goal of treatment of opiate dependency is to learn to live without abusing drugs. Buprenorphine treatment should continue as long as necessary to prevent relapse to opiate abuse/dependence and then be weaned off.
• If I have been on Methadone maintenance, I agree that my provider can coordinate my medication switch with the provider of Methadone. This may involve exchange of medical records and discussions with the Methadone clinic, physician or staff. After switching to Buprenorphine, I will not take Methadone.
• I understand that the fee for our servies ONLY covers our visit fee. This fee DOES NOT include the cost of medications, or any other services provided.
• I will submit a urine specimen for drug screen (narcotics, cocaine, amphetamine, PCP, alcohol, benzodiazepine, and others) upon my provider’s request at a minimum of every 4 weeks and as often as directed. My Buprenorphine provider may ask that a clinical staff member observe me providing the appropriate urine specimen. If my drug screen indicates the presence of illegal/ inappropriate substances, or has no buprenorphine or buprenorphine metabolites, I may be discharged.
• I understand that I will be required at any time with short notice to bring in my medication for my Buprenorphine provider to inspect, count and/or destroy. If I do not show or have the appropriate number of pills, I may be discharged. I may never dispose of Buprenorphine myself without a staff member as a witness.
• I allow my provider to communicate with other providers regarding my medical care, consistent with HIPAA guidelines. Treatment disclosure may include, but is not limited to, discussing my medications with the pharmacist. I understand that records released may contain information pertaining to psychiatric treatment and/or treatment for alcohol and/or drug dependence. These records may contain confidential information about communicable diseases including HIV (AIDS) or related illnesses.
• I will not sell, share, or trade my medication with anyone. It is understood that if caught doing so, I will be discharged without the chance to be readmitted.
• I will safeguard my written prescription and medication from loss, damage or theft. We recommend a lock box especially for those with children. Lost, stolen or damaged prescriptions/medications may be replaced at the provider’s discretion. If replaced, no prior authorization will be completed and you will be responsible for any prescription costs in such cases.
• I will never alter a prescription in ANY way. I understand this is a felony, punishable by incarceration.
• I authorize the Buprenorphine provider and my pharmacy to cooperate fully with any city, state, or federal law enforcement agency, including the State’s Board of Pharmacy and the DEA, in the investigation of any possible misuse, prescription forgery, sale or any other diversion of my medication.
• I will allow my Buprenorphine provider to receive information from any pharmacy I have used.
• I understand that rude or disrespectful treatment of staff is not tolerated and may result in my discharge. (Ex: using profanity, raising my voice, making vulgar or inappropriate comments).
• [For women of childbearing potential] I agree to tell my physician if I become pregnant or even think I may be pregnant.
• I understand that I must provide a viable contact number at all times (and will update the office of any changes) or my provider may not prescribe medications.
• I understand the commitment to the program and the many appointments, therefore transportation cannot be an issue or a reason for short notice cancelations or no show appointments.
• I understand that my prescription will need to be filled immediately following my appointment while our staff is still available to take care of any questions or issues at the pharmacy.

INFORMED CONSENT FOR TREATMENT DURING PREGNANCY

I agree to receive psychiatric care and/or substance use disorder treatment from the Care Clinic. My obstetrician will provide my pre-natal care. During my pregnancy, if I am being treated for a substance use disorder or pain and taking or being prescribed buprenorphine, I may be switched from the combination tablet of buprenorphine with naloxone (Suboxone®) to the non-combination buprenorphine tablet (Subutex®) as recommended by national addiction treatment guidelines. I have met with my provider at Care Clinic and s/he has discussed with me and I understand the risks and benefits of taking buprenorphine and/or psychiatric medications (psychotropics), including but not limited to anti-depressants, gabapentinoids, sleep aids and antipsychotics, during my pregnancy. I have been informed that babies whose mothers took certain psychiatric mediations and buprenorphine during pregnancy have been found to have an increased risk of respiratory problems and birth defects. I have also been informed that the federal Food and Drug Administration (FDA) has not approved the use of buprenorphine for the treatment of opioid addiction in pregnant women. Whereas, methadone has been FDA approved for the treatment of opioid addiction during pregnancy and there is over 40 years of experience showing methadone treatment to be safe and effective during pregnancy. Therefore, it is currently believed that methadone is safer than buprenorphine for the treatment of opioid addiction during pregnancy. Currently there is too little information available to say that buprenorphine is completely safe during pregnancy. Buprenorphine has caused some bone problems in laboratory animal embryos and fetuses after injections of buprenorphine but not when the same amount of buprenorphine was given by mouth. A possible problem of taking any opioid (heroin, methadone, or buprenorphine) or psychiatric medication during pregnancy is that after birth the child may suffer a withdrawal syndrome called Neonatal Abstinence Syndrome. Babies with Neonatal Abstinence Syndrome may suffer from sleep disturbances, feeding difficulties, tremor, sneezing, irritability, vomiting, weight loss, and seizures. A large proportion of these children will require hospitalization, often for long periods of time. I understand these risks and benefits and have decided to take buprenorphine rather than methadone, and have decided to take any other psychiatric medication prescribed by the Care Clinic during my pregnancy. I understand that there are no approved psychotropics have an FDA category A rating, which is a rating that means that controlled studies show no fetal risks associated with the drug. I understand that medical knowledge on the actual or potential risks of buprenorphine and psychiatric medications on pregnant women and unborn children is not at all certain. I accept responsibility for this decision. On behalf of myself and my unborn child, I hereby release and agree to hold harmless, the program, the prescribing doctor, and the program’s officers, directors, agents, and employees from any liability of any kind which may arise in connection with my taking buprenorphine and/or any psychotropic medications during the duration of my pregnancy.

I have received information about my medications from the prescriber, and I consent to this treatment. I understand I can ask questions about my medicines at any time (INFORMED CONSENT). I agree not to change the medication(s) dosage without first consulting with the prescriber. I was advised to discuss drug interactions and special instructions with the dispensing pharmacist.

By signing this form, you indicate the medications have been explained to you to your satisfaction.

Even after signing, you can still refuse any dose or withdraw your agreement completely at any time.

You may request a copy of this consent form at any time.

ABN FORM:

Courtesy Advance Beneficiary Notice of Noncoverage (ABN)

NOTE: If Medicare/Medicaid doesn’t pay for the services below, you may have to pay. Medicare/Medicaid does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare/Medicaid may not pay for the services below.

SERVICES: OFFICE CONSULTATION

REASON MEDICARE/MEDICAID MAY NOT PAY: The provider is out of network with Medicare/Medicaid and/or does not pay for the specific services listed because those services are not covered under your plan with Medicare/Medicaid.

ESTIMATED COST: $205-$230

WHAT YOU NEED TO KNOW: 

– Read this notice, so you can make an informed decision about your care

– Ask us any questions that you may have after you finish reading.

– Choose an option below about whether to receive the services listed above.

NOTE: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this:

OPTION 1:

I want the medical services listed above. You may ask to be paid now, but I also want Medicare/Medicaid billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare/Medicaid doesn’t pay, I am responsible for payment, but I can appeal to Medicare/Medicaid by following the directions on the MSN. If Medicare/Medicaid does pay, you will refund any payments I made to you, less co- pays or deductibles

OPTION 2: 

I want the medical services listed above, but do not bill Medicare/Medicaid. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare/Medicaid is not billed

OPTION 3:

 I don’t want the medical services listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare/Medicaid would pay.

ADDITIONAL INFORMATION: 

This notice will remain active with Care Clinic and your provider for as long as you are an active patient with Care Clinic and it’s providers. Please inform us of any changes to your insurance that might affect this notice. Unless otherwise informed, Care Clinic and it’s providers will assume this notice to remain active and current for the duration of your treatment as a patient with Care Clinic.This notice gives our opinion, not an official Medicare/Medicaid decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633- 4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy.

I have chosen to select OPTION 2

The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.