Your answers to the following questions will help us to understand your medical history and the concerns you’d like to discuss with your doctor. Please fill out as much of this questionnaire as possible. If you cannot answer some of the questions or feel uncomfortable answering them, leave them blank. Thank you for your help.

Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable healthcare providers to deliver healthcare services to patients when located at different sites.

I understand that the same standard of care applies to the telemedicine visit as applies to an in-person visit.

I understand that I will not be physically in the same room as my healthcare provider. I will be notified of and my consent obtained for anyone other than my healthcare provider presents the room.

I understand that they are a potential risk of using technology, Including service interruptions, interceptions, and technical difficulties.

a. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my healthcare provider or I am may discontinue the teller's medicine visit and make other arrangements to continue the visit.

I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.

I understand that the laws that protect the privacy and the confidentiality of my healthcare information apply to telemedicine services. I understand that my healthcare information is shared with another individual for scheduling and billing purposes.

a. I understand that my insurance carrier will have access to my medical records for quality review/audit.

b. I understand that I will be responsible for any out-of-pocket costs such as copayments or coins insurance that apply to my telemedicine visit.

c. I understand that health plan payment policies for telemedicine visits may be different from the policy for in-person visits. I understand that the document will become a part of my medical records.

By signing this form and/or giving verbal consent, I attest that I (1) have personally read this form (or had explained to me) in fully understand agree to its contents; (2) have my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visit shared with me in the language I understand; and (3) located in the state of Texas and will be in Texas during my telemedicine visit(s)

(a)The Black Effort Against the Threat of Aids (BEAT AIDS) is required by federal law to maintain the privacy of your Person Health Information (PHI) and to provide you with this Privacy Notice detailing the practice’s legal duties and privacy practices with respect to your PHI.

(b)Under the Privacy Rule, BEAT AIDS may be required by state law to grant greater access or maintain greater restrictions on the use or release of your PHI than is provided for under federal law.

(c)BEAT AIDS is required to abide by the terms of this Privacy Notice.

(d)BEAT AIDS reserves the right to change the terms of the Privacy Notice and to make the new Privacy Notice provisions effective for your PHI that it maintains.

(e)BEAT AIDS will distribute any revised Privacy Notice to you prior to implementation.

(f)BEAT AIDS will not retaliate against you for filing a complaint.

(g)Health Insurance Privacy Act 1996 requires we inform you that we will not ever share, sell, or “SPAM” your personal contact information to business, educational, or health-related marketing companies.

I acknowledge receipt of this notice and my understanding and agreement to its term.

I authorize you to contact me via the methods checked for other Health-related topics at the number and/or email below. I understand that for text messages, Message and Data Rates May Apply, and telephone calls may include pre-recorded messages. I understand that I can opt-out at any time y informing the front desk or case manager.

 

By signing this consent form, you are stating your willingness to accept Referral Navigation services at this time. When the time comes that you are no longer in need or want Navigation services, simply state this to your Navigation Specialist and services will cease. The Navigation Specialist can meet with you at a place of your choosing and at a time that is convenient for both of you. Navigation services require asking personal questions about your medical stats, sexual behaviors, substance abuse, and your living situation and/or behaviors. We will work together to help initiate proper medical care, mental health services, medication acquisition, and basic need acquisitions to help you stay as healthy as possible.

Confidentiality

The information we talk about and your records will be kept confidential in accordance with all HIPPA laws and regulations, except for certain circumstances explained below. Any written documentation or notes the Navigation Specialist takes are kept in a locked office and in a locked room. Anyone who releases or makes public any private health reports or violates in any way your confidentiality is guilty of a misdemeanor and, upon conviction shall be punished by a fine of no less than $500.00 not more than $5000.00 or imprisonment in the county jail for not less than six months, not more than twenty-four months, or by both fine and imprisonment.

A Navigation Specialist is bound by law to report to the proper authorities any information that may lead to Navigation Specialist to believe that you may cause harm to yourself or to others.

If the Navigation Specialist suspects that a child has been abused or neglected, abuse to the elderly, the potential harm to others, or potential for self-inflicted harm, the Navigation Specialist must report the following information to the Department of Social Services for investigations. The Navigation Specialist will report:

1. The name, addresses, and sex of child/elderly/person at risk of harm/ client at risk of self-inflicted harm

2. The name and addresses of the person responsible for the child/elderly

3. The name and addresses of the person who is alleged to be responsible for the suspected abuse or neglect, if known; and

4. The general nature of the child/elderly/person at risk of harm/client of potential for self-injury.

The above holds true even if you are no longer a client and if your Navigation Specialist no longer works for this agency. They may still be called to testify against you.

If you have any questions or concerns about Client Navigation or the services I am providing you, contact me at (210) 212-2271

A signed copy of your voluntary consent form (this document), as well as your care plan, must be in your file.

I have read these pages or have had them read to me and have had a chance to have my questions answered. I understand the information on this form. My signature indicates that I fully understand all aspects of this program.

As a client of BEAT-AIDS COALITION TRUST receiving Navigation services, you have the following rights and responsibilities:

A. Rights:

1. To be served without regard to age, gender, gender identity, race, religion, sexual orientation, or disability.

2. To services that are considerate and respectful, and free from abuse, neglect, and exploitation.

3. No information that would directly or indirectly reveal your HIV status may be disclosed to anyone outside the agency without your informed written consent, as governed by local, state, or federal law (exception: subpoenas from a court of law whom there is reasonable concern that may harm themselves or others.)

4. To communicate about your services and to be informed of the agency’s grievance policy/procedure.

5. To be informed of all agency rules and regulations related to your services.

6. To initiate a complaint about your services and to inform the agency without pressure or intimidation.

7. To withdraw your consent for services and/or seek services at another agency without pressure or intimidation.

 

B. Responsibilities:

1. To participate in the development and implementation of your experience.

2. Inform your Navigation Specialist when you do not understand the instructions or information that you receive.

3. To keep your scheduled appointments with your Navigation Specialist, and notify them when you need to cancel or reschedule.

4. Follow through on those activities that you agree to perform and to notify your Navigation Specialist when you are unable to do so.

5. Conduct yourself appropriately and respectfully. Inappropriate behavior includes, but is not limited to, intoxication, threats, harassment, physical and/or verbal abuse.

6. Communicate your needs to your Navigation Specialist so that appropriate action may be taken to meet your needs

 

C. Complaints

1. To file a complaint, contact Jose Chavarria at (210) 212-2271.

 When a client has a grievance or complaint, the following steps shall be followed in resolving the matter.

1. Grievance/Complaint: First the client shall discuss the matter with the Department Head involving the employee and/or employees. Every effort should be made to resolve the problem at this level. If a problem is not resolved, the client has the right the put their complaint/grievance in writing.

2. Executive Director’s Decision: If a complaint/grievance is made in writing, the Executive Director will investigate that matter and corrective action will be taken to satisfy the client.

a.) If the investigation merits disciplinary action against the employee, they will be disciplined according to the Personnel/Procedure Manual.

b.) If the client is not satisfied with the Executive Director’s decision, the Client may ask in writing for a hearing before the Board, where both parties may be represented by an attorney.

c.) The Board may assign a committee of the Board to hear the case, i.e., Personnel Committee or Grievance Committee.

d.) The board may reserve the right to refuse such a hearing. The refusal should be in writing not to exceed ten (10) days from the date of the request.

**This is to be given and explained to the client before the consent for services forms is signed and dated.**

BEAT AIDS COALITION TRUST (Client Navigation) On this day I have met with program staff of BEAT AIDS COALITION TRUST and have discussed the services available through the variety of program areas. I understand that as my needs change I may request additional services. Depending on which services I have requested, I know that I may be contacted by program staff or volunteers. In order to receive these services in a timely manner, my name and phone number may be given directly to the program staff or volunteer service provider. These individuals each uphold BEAT AIDS COALITION TRUST policy and confidentiality and I feel comfortable in the knowledge that I will receive only professional and respectful treatment. I further understand that program staff will work directly with my physician when it is necessary to acquire public and private benefits on my behalf. BEAT AIDS COALITION TRUST maintains Qualified Service Organization Agreements (QSMB) with other related services as well as other community organizations. This allows program staff the ability to communicate with one another regarding information limited to the specific service requested. When at all possible, I will contact the appropriate program staff with my needs in a timely manner so as to assure appropriate and timely service. In the event of an emergency, I can expect that every effort will be made to meet my needs. I also understand that at times, circumstances may be beyond the control of program staff and that my need may not be met to my satisfaction. In these instances, the program staff will inform me of the difficulties in accessing services. 

Privacy and Confidentiality

As a client or patient of BEAT AIDS COALITION TRUST, you have the right to privacy and the right to review information which is kept in your record, BEAT AIDS COALITION TRUST is in compliance with all HIPPA guidelines, laws, and regulations.

A. Access to your record: Records are maintained to summarize what has taken place during each of your meetings with program staff. Records are also maintained on any follow-up contacts with either you or your services providers. You have the right to look at or obtain copies of documents in your file.

B. Release of your records to others and limits of confidentiality and privacy: No one may have access to your record without a signed consent form from you, except in the following circumstances, where mental health professionals and program staff are required by law to release information.

1. When a client threatens to harm or has harmed themselves or others.

2. When a client has committed a crime or intends to commit a crime.

3. When BEAT AIDS COALITION TRUST receives a subpoena of case records for Court proceedings. This means that your records are not available to your employer, prospective employer, your family members, or to other agencies without your consent.

C. Case consultation: Program staff of BEAT AIDS COALITION TRUST and its service programs routinely consult with other providers regarding your needs. These may be individual or group consultations involving mental health, social service, medical staff or public and governmental assistance programs. This consultation authorization is also intended to include disclosure of HIV testing and other information related to HIV and AIDS to assist you in obtaining necessary benefits and services.

D. Staff: All of BEAT AIDS COALITION TRUST paid and volunteer program staff are professionally trained and supervised.

 

Grievance/Complaint Policies and Procedures

E. Grievance Procedure: If at any time you feel that you are not receiving appropriate services from any paid or volunteer program staff off BEAT AIDS COALITION TRUST you should immediately contact the BEAT AIDS COALITION TRUST Client Advocate to assist you in resolving the situation.

I have read and had explained to me BEAT AIDS COALITION TRUST Service Agreement. I understand and agree with the service provision. A signed photocopy of this Service Agreement shall be considered as valid as the original. 

I give consent to be transported by BEAT AIDS COALITION TRUST employee or a BEAT AIDS COALITION TRUST vehicle. I agree that BEAT AIDS COALITION TRUST, or any employee thereof, will not be held liable for any accident or injury occurring during transportation.

1. I understand that Truvada/Descovy are the medications used for PrEP.

2. I understand that I will be evaluated to see if PrEP is appropriate for me and I may not be eligible for PrEP if I have certain medical conditions.

3. I understand that while PrEP can be highly effective at preventing HIV infection, there is still a chance that I can get HIV if I don’t properly take the medication every day.

4. I understand that my provider will review the potential side effects of PrEP including but not limited to kidney problems, bone loss, nausea, and vomiting.

5. The better I am at taking my pill every day the more protection I will have against HIV.

6. I understand it will take 1 week before I have maximum protection from PrEP.

7. I understand that if I become infected with HIV while on PrEP there is a possibility that PrEP will no longer work for me.

8. I understand there are some medications I shouldn’t be taking with PrEP and I will notify personnel of any changes in the medications I take.

9. I understand that PrEP does not prevent syphilis, gonorrhea, chlamydia, hepatitis B or C, or pregnancy.

10. PrEP is just a part of my comprehensive sexual health strategy that includes other risk reduction strategies that are appropriate for me.

11. I understand that I need to have my health monitored while on PrEP and I will do my best to attend my follow-up appointments.

I understand that if I do not provide or have active medical insurance a $25 STI treatment service fee or a $50 HRT will be applied to me for my STI and/or HRT visit.

This health information may be used to enable the persons I authorize to know and understand my condition and my treatment or treatment options, for treatment or consolations, for claims payments purposes, or related reasons.

This authorization shall be effective for one year (Date from: ________ to _______). After that, this form will be terminated and renewal will be submitted. NOTE: You may revoke this authorization in writing at any time by notifying one of our clinic staff, health care providers, or any BEAT employee, preferably in writing.