In accordance with the Health Insurance Portability and Accountability Act of 1996, as of April 14, 2003 all health care providers are required to provide their patients with a "Notice of Privacy Practice' statement.

 

NOTICE OF HIPAA PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

JADE Wellness Center is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our clients with notice of our legal duties and privacy practices with respect to your protected health information

Disclosure of Your Health Care Information

Treatment

We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. For example, on occasion, it may be necessary to seek consultation regarding your condition from other health care professionals associated with JADE Wellness Center.

Payment

We may disclose your health information to your insurance provider for the purpose of payment of health care operations. For example, as a courtesy to our clients, we will submit an itemized billing statement to you and/or your insurance carrier for the purpose of payment to JADE Wellness Center for health care services rendered. The billing statement contains medical information, including diagnosis, date of condition and codes that describe the health care services rendered.

Workers' Compensation

We may disclose your health information as necessary to comply with State Workers' Compensation Laws.

Emergencies

We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or your death.

Public Health

As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications and reporting disease or infection exposure.

Juridical and Administrative Proceedings

We may disclose your health information in the course of any administrative or judicial proceeding.

Law Enforcement

We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a good cause court order or subpoena and other law enforcement purposes.

Deceseased Persons

We may disclose your health information to coroners or medical examiners.

Organ Donation

We may disclose your health information to organizations involved in procuring, banking or transplanting organs and tissues.

Research

We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.

Public Safety

It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.

Specialized Government Agencies

We may disclose your health information for military, national security, prisoner or government benefits purposes.

Appointment Reminders

We may contact you for purposes of reminding you that you have an appointment for treatment at our office.

Change of Ownership

In the event that JADE Wellness Center is sold or merged with another organization, your health information/record will become the property of the new owner.

Your Health Information Rights

You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that JADE Wellness Center is not required to agree to the restriction that you request. You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication of delivery, upon your request. You have the right to inspect and copy your health information. You have the right to request that JADE Wellness Center amend your protected health information. Please be advised, however, that JADE Wellness Center is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial. You have a right to receive an accounting of disclosures of your protected health information made by JADE Wellness Center. You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

Changes to this Notice of Privacy Practices

JADE Wellness Center reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, JADE Wellness Center is required by law to comply with this Notice.

JADE Wellness Center is required by law to maintain the privacy of your health information and to provide you with notice of its' legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact the HIPAA Privacy Practice Officer by calling our office at the number listed in the Client Handbook.

HIPAA Disclaimer

Releases of information permitted by HIPAA regulations which are prohibited by the Federal and State Confidentiality Laws for substance abuse treatment, continue to be prohibited and will require the client's written consent.

Complaints

Complaints about your Privacy rights or how JADE Wellness Center has handled your health information should be directed to the HIPAA Privacy Practice Officer at JADE Wellness Center. If s/he is not available, you may make an appointment for a personal conference in person or by telephone within two working days. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS
Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, D.C. 20201

 

I have read the Privacy Notice and understand my rights contained in this notice.

By way of my signature, I provide JADE Wellness Center with my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment and healthcare operations as described in the Privacy Notice.

Federal and State Laws and regulations protect the confidentiality of client records maintained by JADE Wellness Center, JADE will not disclose any information identifying a client as a recipient of treatment services unless:

1. The client consents in writing; or
2. The disclosure is permitted by a good cause court order;
3. The disclosure is made to medical personnel in a medical emergency; or
4. The disclosure is made to "qualified personnel" for audit or program evaluation (for licensing and accreditation of the facility, those responsible for assuring compliance with the contract standards or provisions are "qualified personnel" in the Commonwealth of Pennsylvania, the Governor's council determines who "qualified personnel" is).

Client Rights

As a client of JADE Wellness Center, you are entitled to the following:

1. Under the Pennsylvania Drug and Alcohol Control Act, Section 7, you shall retain all civil rights and liberties except as provided by law.  No client shall be deprived of any civil rights solely by reason of involvement in drug and alcohol treatment
2. JADE Wellness Center shall not discriminate on the basis of age, race, creed, ethnicity, national origin, martial status, sexual orientation, handicap or religious preference. 
3. You have the right to inspect your record.  The Facility Director or Certified Recovery Specialist Supervisor may temporarily remove portions of you record prior to your inspection when she/he determines that the information may be detrimental to you if presented.  The reason for the removal will be documented as part of your record.  The following procedure is to be followed when requesting review of your record:

a.       Submit a written request to JADE Wellness Center staff stating the reason(s) you are requesting to review your record.

b.       Sign and date the request.

Submit request to any staff member who will present the request, along with your record to the Facility Director.  Both the Certified Recovery Specialist and the Facility Director will be present with you as you review your record.  All such requests will be honored within 7 days of your request.  You may request a correction or removal, if the information is inaccurate, irrelevant, or incomplete.  Appeal related to the retention or destruction of record contents are to be mediated by the Facility Director.  You may submit rebuttal data or a memorandum to your record.

Services Provided

• Screening, ASsessment and referral
• Individual peer-to-peer recovery planning.
• Group recovery planning
• Relapse prevention
• Early Intervention
• Outreach, Support and Guidance
• Mentoring
• Goal Setting
• Face-to-face sessions with CRS
• Telephonic support sessions with CRS
• Virtual/Telehealth support sessions with CRS

Consent to Treatment

1. I agree to keep and be on time to all my scheduled appointments.
2. I agree to adhere to the payment policy outlined by this program. If I have medical coverage/Health Insurance that will cover the cost of my treatment, I agree to provide JADE Wellness Center with the necessary documents which will allow them to bill my Medical/Health coverage provider.
3. I agree to conduct myself in a courteous manner in the JADE Wellness Center.
4. I agree not to deal, steal or conduct any illegal or disruptive activities in the JADE Wellness Center Program.
5. I agree to participate in the development of and compliance with the goals and objectives in my Recovery Plan.
6. I understand that violations of the above may be grounds for termination of treatment. 

Client Responsibilities

While active in JADE Wellness Center’s CRS services, you will be expected to adhere to the following.

1.       Clients are expected to abide by all treatment recommendations made by treatment staff.

2.       Clients who are unable to attend a scheduled appointment must call 24 hours in advance.

3.       3 No Call/No Sow to scheduled appointments could result in immediate discharge from treatment.

4.       Please be on time.  There is a 15-minutes late policy at JADE Wellness Center.  If you are more than 15 minutes late you will be asked to reschedule.

5.       Clients must submit to random breathalyzers and urine analysis screens.  Failure to submit will be considered a positive screen and may result in a referral and/or adaptation to client’s plan of care.

6.       Clients are not permitted to wear clothing that depicts or advertises alcohol or other substances.  No attire depicting sexual/violent/gang related acts.

7.       Clients are to refrain from the use of cell phones and electronic devices during treatment.

8.       No violent behaviors or acts will be tolerated on JADE Wellness Center property.  No use of obscene language or gestures.

9.       Clients are expected to be honest, open minded and willing during treatment.

10.   FEE SCHEDULE:  Not all insurance providers cover CRS services at this time.  If services are not covered by your insurance or you are uninsured there will be a $40 an hour charge.

Clients who are unable to attend a scheduled appointment must call and speak directly with a staff member. All cancellations should be made 24 hours in advance.

Abusive behaviors include (but is not limited to):

• Verbal abuse such as swearing or screaming at staff.
• Physical abuse such as hitting, kicing, grabbing, or spitting at staff.
• Harrassment such as threatening staff or making any discriminating comments based on race, gender, religion, disability, or age.
• Sexual harassment including sexually-based comments, jokes, photos/videos, or any inappropraite touching or gestures made towards staff.

Description of Services:

The primary function of the CRS is to help individuals gain access to needed resources in the community by assisting them in overcoming barriers and helping them bridge gaps between their needs and available resources.  The CRS will be responsible for outreach, support, and guidance for individuals in the identified target population.  Services will include outreach, mentoring, peer support and guidance, as well as resource information and referral.  A CRS will work closely with individuals before, during, and after their treatment experiences to support and assist them in their recovery.  In understanding and navigating the system of care, as well as to encourage and guide any necessary connections with other services system.

Explanation of CRS Services

My signature indicates I agree to participate in Certified Recovery Services (CRS).  I understand that CRS services will provide:
Guidance in the recovery process
An appropriate recovery plan which will include both long-term and short-term goals.
Referral for needed support services.
Referral for self-help recovery services.
Moral support, coaching and advocacy throughout the recovery process.
Guidance in building healthy social relationships to support recovery.
Access to vital community services and supports.

 

 

Payment Policy & Fee Schedule

 

The fee schedule is posted in the main lobby of the facility and in your initial client handbook. If you need an additional copy you may request one and it will be given to you.

If you need an additional copy, you may request one. I understand the full payment is required at the time of service by either cash or credit card.

I also understanding that the financial responsibility for services is mine, and that I must provide any information regarding active insurance to JADE Wellness Center

I understand that if the credit card charge is denied, I will be billed separately for the appointments. I understand that I must pay for any outstanding balance in full before receiving further services.

I agree to call and notify the receptionist in advance of my next scheduled appointment if my address, phone number, or responsible party has changed.

 
Acknowledgement of Receipt of Client Handbook

I acknowledge that I have received a copy of the JADE Wellness Center Handbook at the time of my admission and that I have been informed that I am free to ask questions about it at any point throughout my treatment. Fees were also discussed with me at the time of my intake.

Informed Consent Telemedicine Services

I understand that it is my obligation to notify JADE Wellness Center of my location at the beginning of each treatment session. If for some reason, I change locations during the session, it is my obligation to notify JADE Wellness Center of the change in location.

I understand that it is my obligation to notify JADE Wellness Center of any other persons in the location, either on or off camera and who can hear or see my sessions. I understand that I am responsible to ensure privacy at my location. I will notify JADE Wellness Center at the outset of each session and am aware that confidential information may be discussed.

I agree that I will not record either through audio or video any of the sessions.

I understand there are potential risks to using telehealth technology, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand some of these technological challenges include issues with software, hardware, and internet connection which may result in interruption.

I am aware that alternative care options including in person visits are available for any services I receive.

I have been trained on how to use telehealth technology by JADE Wellness Center.

Telehealth is NOT an emergency service. In the event of an emergency, I will use a phone to call 911.

To maintain confidentiality, I will not share my telehealth appointment link or information with anyone not authorized to attend the session.

I understand that either I or JADE Wellness Center can discontinue the telehealth services if those services do not appear to benefit me therapeutically or for other reasons which will be explained to me. I have read and understand this consent to treatment and the associated telehealth policies. By providing my signature I am acknowledging my informed consent to engage in Telehealth Virtual care services.

Emergency and Psychiatric Consent

I consent to allow Journey to procure for me in the event of a medical or psychiatric emergency and release JADE from all liability related to any injury which may occur during my treatment at this facility.

I understand that I may revoke all or part of this authorization verbally or in writing.
Please contact the office if you wish to revoke this consent.

This Consent/Authorization complies with the Privacy Regulations contained within Federal Register Vol. 65, Part II, Part 164; SubPart E 164.508.

PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law.  Federal regulations prohibit you from making any further disclosures of this information except with the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations.  A general release of medical or other information is NOT sufficient for this purpose.