Journey 2 Health

Welcome to the Journey 2 Health Program!  

Serving the residents of the Recovery Soldier’s Ministry Program 

We are so glad you decided to become a resident of Recovery Soldier’s Ministry as you pursue what God can do in your life. We are here to help you on that journey. While you are focused on recovering from an addiction of some kind, you may have basic physical health needs with which we can help. Journey 2 Health is a physician-driven program intended to serve your needs of physical health. From high blood pressure to a sore throat, we are focused on providing you access to a physician trained in general prevention and primary care. We offer video visits for basic physical health needs. We occasionally have in-person “at-home” clinic visits at the RSM facilities. Based on your medical needs, we can continue basic primary care while you are a resident in RSM. This program is offered at no cost to you by Partners for Health, PLLC.

After completing this packet, please coordinate with Recovery Soldier’s Ministry to schedule your first visit! And we CANNOT provide care to you without this form being completed in its entirety.

Thank you! 

"Dr. Troy"

Troy E. Sybert, MD

Partners for Health, PLLC

525 W. Oakland Ave., Suite 6 

Johnson City, TN 37604 

Please note upon leaving the RSM program, you are NO longer eligible for the Journey 2 Health Program.

Your medical records can be made available to you upon request.  Upon leaving the RSM program, Partners for Health can continue to provide care to you if you enroll in our P4H Subscription Program.  Subscription fees will apply. Partners for Health PLLC is defined as all healthcare providers, employees, independent contractors, and volunteers.

 

Please type your name indicating your understanding of eligibility if you leave the program as described in the preceding paragraph.

PATIENT DEMOGRAPHIC INFORMATION 

Directions: Please complete this form indicating you will be enrolled in the Journey 2 Health Program Provider Services as offered by Partners for Health, PLLC. This form serves as the notice the resident is to receive services as of the Start Date. Please include the projected End Date. If one is not known or entered, services will continue until a 30-day written notice is given and the resident is no longer to receive services. The email address is used to access the patient’s individual medical record inside the electronic medical record. Please note the resident is ONLY offered these services while enrolled in the RSM program.

Please note you will need to type your name multiple times in this form indicating your understanding of the terms and conditions of this program.  You will also need to electronically sign the form once you are completed.

The following mailing address and phone number is used as the address of record while the resident is in the RSM Program:

P.O. Box 603

Elizabethton, TN 37644

(423) 518-1450

If you wish another address or phone number used, please indicate the address and phone in the following fields, otherwise please leave blank.

There are 3 programs offered through Partners for Health for residents of RSM.

1. Medical Only: This program is designed for people needing only basic primary care. It does not include the management of mental health conditions.  Participants in this program may need blood pressure medications or have the occasional sore throat needing an antibiotic.

2. Mental Health: While also allowing for medical care, this program also helps you with mental health conditions requiring medication management.

3. Intensive Outpatient Program: This program includes both the medical and mental health aspects, but is specifically focused on helping you in a targeted effort.  Please check with the staff at RSM and confirm if you believe you need this program. THIS PROGRAM IS ON HOLD

PLEASE READ THIS STATEMENT AND CHECK THE RESPECTIVE BOX 

The RSM Program relies on RSM staff and volunteers to facilitate communication and telemedicine visits given the program rules. Oftentimes, we must communicate the need to pick up prescriptions or to schedule and facilitate visits with the staff and volunteers. We also communicate by email to both RSM and your assigned email while in the program.  We do have official agreements between RSM and Partners for Health covering the exchange of protected health information. If you do not wish to have your medical care facilitated in this way, please indicate that choice. 

CONSENT TO TREAT: 

I, the undersigned, do hereby consent and agree to the following: 

General Consent: I voluntarily consent to receive medical care and treatment as deemed necessary by the healthcare providers at  Partners for Health PLLC, including but not limited to diagnostic tests, examinations, and medical treatment. 

Additional Specific Consent: As part of high quality treatment, I authorize Partners for Health to obtain my medication list  electronically as needed. 

Understanding Risks: I understand that there are risks, benefits, and alternatives associated with any medical procedure or treatment,  and the healthcare providers have explained these to me to my satisfaction. 

Release of Information: I authorize Partners for Health PLLC to release any information acquired in the course of my examination and  treatment to other healthcare providers as necessary for medical care and payment purposes. 

Right to Withdraw Consent: I understand that I have the right to withdraw my consent at any time. 

BY PARTICIPATING IN TELEHEALTH, I GIVE CONSENT to Partners for Health PLLC and 

I understand that my health care provider wishes me to engage in a telehealth consultation. 

My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not  be the same as a direct client/health care provider visit since I will not be in the same room as my provider. 

I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a  location of my choosing. 

I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I  understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing  connections are not adequate for the situation. 

I have had a direct conversation with my provider, during which I had the opportunity to ask questions regarding this procedure. My  questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in  which I understand. 

BY PARTICIPATING, I acknowledge Telehealth is NOT an Emergency Service and in the event of an emergency, I will use a phone  to call 911. Though my provider and I may be in direct, virtual contact through the Telehealth Service, the service provides no medical  or healthcare services or advice including, but not limited to, emergency or urgent medical services. 

To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

HIPAA DISCLOSURE AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES - YOUR RIGHTS AND RESPONSIBILITIES 

We understand that health information about you is personal, and we are committed to protecting that information. We are required by law to ensure that health information that identifies you is kept private, to follow the terms of this notice, and to give you this notice of our legal duties regarding health information and you. 

You have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. You may not be able to revoke this authorization if its purpose was to obtain insurance. To revoke this authorization, you must do so in writing and send it to the appropriate disclosing party. 

You understand that uses and disclosures already made based upon your original permission cannot be taken back. 

You understand that treatment by any party may not be conditioned upon your signing of this authorization and that you may have the right to refuse to sign this authorization. Refusal to sign will not affect your ability to obtain treatment except to the extent that the information being released or requested may assist your healthcare provider in determining the appropriate treatment.  

This authorization is effective for the above requested and authorized health care information only. You may ask for and receive a copy of this form. A copy of this form is as valid as the original. 

The information you are authorizing to be released could be re-released or disclosed by the recipient. Such additional disclosures or releases may not be prohibited by law. We are not responsible for the actions of others who may be provided with the information released as a result of this authorization. 

We may use and disclose health information about you for your care and treatment including coordination of care, referrals, health care operations - such as billing and payment, appointment reminders, as required to perform various office and administrative functions, to avert serious threats to health and safety, and as required by law. 

Your rights regarding health information about you include the right to inspect and copy records, to amend records, to account for disclosures, to request confidential communication electronically or by paper and to a paper copy of this notice (available upon request). 

This acknowledgement will become a part of your records. We reserve the right to change this notice. 

If you have questions or concerns about your privacy rights, you may contact our office with your inquiry. Inquiries must be in writing. Please address inquiries to: 

Partners for Health 

525 W. Oakland Ave., Suite 6 

Johnson City, TN 37604

FINANCIAL POLICY AND ACKNOWLEDGEMENTS 

Thank you for choosing to become a patient and client in our clinic. Please take a moment to review and sign our Financial Policy. 

Partners for Health does NOT accept insurance. Partners for Health CANNOT accept patients that have Medicare Insurance. This also includes Medicare Advantage Plans.  

I attest that I do NOT have any Traditional Medicare and/or I do NOT have any Medicare Advantage Insurance Plan.

Financial Responsibility:

RSM Residents are covered through the Journey 2 Health Program, a partnership between Recovery Soldiers Ministry and Partners for Health. There is no cost to the resident. 

Insurance Participation: Partners for Health does NOT accept any form of insurance from RSM residents.

Medicare/Medicaid/Military: Partners for Health does not participate with these entities.

ACKNOWLEDGEMENTS AND AUTHORIZATIONS 

By entering your full name in the field just below, you acknowledge that you have read and understand the financial policy information provided above.

AUTHORIZATION TO USE ELECTRONIC MEANS OF COMMUNICATION 

This practice uses a secure electronic medical records database (EMR). Signing this consent form will provide you future access to  your electronic medical information, and also secure internal messaging. It is also the most secure way to send or receive medical  information electronically.  

I authorize my healthcare providers to communicate with me using electronic means of messaging via the EMR, and, if I chose, also  via email, for matters pertaining to my healthcare. I understand that this method of communication is agreed to solely as a  convenience for me and is not a condition of care to be rendered by my provider.  

Regarding privacy, I acknowledge that the use of email entails additional risks of loss of confidentiality including but not  limited to interceptions of messages during the transmission, storage, and retrieval processes, and unauthorized or  inadvertent access to the messages once stored on the sender's and recipients' computers, and that these risks may be beyond  the control of either entities. I also acknowledge that email correspondence may be printed and become a permanent part of  my medical record. 

Regarding this communication, I understand that email or messaging (via the EMR portal) use will be limited to administrative  questions, scheduling, and minor clarifications, such as Care Plans or nutritional protocols. 

I fully understand that there may be delays in my messaging or email inquiries and that my providers are under no obligation  to read or response immediately, and so for these reasons, I understand I should contact local emergency services for any  health emergencies or issues which could potentially adversely affect my medical conditions. 

I understand that electronic communication can also be affected by computer hardware or software problems, and other such  incidents beyond the control of my providers. 

I understand that should any emergency medical condition occur; I will seek appropriate assistance through an Emergency  Room and that electronic communication is not to be used for such an event. 

I further agree that extensive messaging or email correspondence, much like telephone discussions, may be subject to charges  for the medical service which they represent, that such charges may not be covered by insurance, and that I will be responsible  for such charges. 

VOICE REMINDERS AND MESSAGING 

I authorize my healthcare providers to communicate with me via phone and /or voice reminders, EMR messaging, or other forms of  electronic messaging such as email and mobile phone SMS text. 

For all RSM residents, please note that communication and facilitation of your care involves the RSM staff and volunteers. This  communication is typically items like the need to pick up prescriptions and schedule appointments. The rules of the RSM residential  program do not allow you to have direct access to email or internet services. This is a function of the RSM Residential Program and  not the Partners for Health policies.  

In compliance of state and federal regulations, Partners for Health (P4H) will not release an individual’s medical records or  information without the patient’s written authorization. The patient may restrict or revoke the authorization to release medical  information at any time. We ask that you instruct us on what medical information can be shared, with whom, and by what means of  communication.

You are all done! Please submit this packet and have the RSM staff schedule your first visit!!