• General Consent to Treatment

    General Consent to Treatment

  • HIPAA Consent Form

  • 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

     

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  • 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.

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  • General Consent to Treatment Authorization

  • Client Responsibilities and Treatment Policy

    During your treatment at JADE, you will be expected to adhere to the following:
    1. Client must maintain abstinence from all psychoactive substances (drugs) and Alcohol during your treatment course with JADE Wellness Center.
    2. Clients are encouraged to attend their choice of support group meetings (AA, NA, DRA, etc..) during your treatment process. If you are unsure if a group meets the requirements speak to your therapist.
    3. Clients are expected to abide by all treatment recommendations made by treatment staff, including therapist, physicians, nurses and staff as applicable
    4. Clients who are unable to attend a scheduled appointment/group must call and speak directly with their therapist at 412-380-0100. ALL calls for cancellations must be received by your therapist 1 hour prior to the start of group.
    5. Clients who have 3 NO SHOWS/NO CALLS will result in immediate discharge from treatment. COMMUNICATE with your therapist.
    6. Please be on time. Any client more than 15 minutes late for group will not be permitted to enter and will count as a NO SHOW, unless prior approval from your therapist has been received.
    7. 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 to a higher level of care.
    8. Clients are not permitted to wear clothing that depicts or advertises alcohol or other substances. No attire depicting sexual/violent/gang related acts. Clients are to refrain from the use of cell phones and electronic devices during treatment. TURN THEM OFF. Please give family members this phone number for emergency use- 412-380-0100.
    9. No violent behaviors or acts will be tolerated on Jade Wellness Center property. No use of obscene language or gestures.
    10. Clients are encouraged to participate in group discussions and be HONEST with yourself, then others in group. EVERYTHING said in group, STAYS in group.

    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).

    Notice Regarding Confidentiality of Client Records


    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 drug and alcohol treatment services unless:
    1. The client consents in writing; or
    2. The disclosure is permitted by a good cause court order; or
    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:

    As a client of JADE, 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 statute. No client shall be deprived of any civil rights solely by reason of involvement in drug and alcohol treatment
    2. JADE shall not discriminate on the basis of age, race, creed, sex, ethnicity, color, national origin, marital 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.

    c. Your therapist will present the request, along with your record to the Facility Director. Both your counselor 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.
    4. Clients have the right to appeal a decision limiting access to their records to the director.
    5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
    6. Clients have the right to submit rebuttal data or memoranda to their own records.
    7. JADE Wellness Center acts as an educational center for master level interns and residencies. All clients have the right to refuse involvement from interns and residents at any time throughout their treatment episode.

    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
    • Care Planning
    • Social Needs Assessment
    • Tobacco Recovery Group & Individual Counseling
    • 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 that will cover the cost of my treatment, I agree to provide JADE with the necessary documents which will allow them to bill my medical coverage provider
    3. I agree to conduct myself in a courteous manner.
    4. I agree not to sell, share, or give any of my medication to another person. I understand that such a mishandling of my medication is a serious violation of the agreement and could result in my treatment being terminated without any recourse for appeal.
    5. I agree not to deal, steal or conduct any illegal or disruptive activities at JADE.
    6. I agree that my prescription can only be given to me at my regular treatment visit. A missed visit may result in my not being able to get my prescription until the next scheduled treatment visit.
    7. I agree that the medication I am prescribed by JADE Wellness is my responsibility and I agree to keep it in a safe, secure, place. I agree that lost medication will not be replaced regardless of why it was lost.
    8. I agree to present my medication the staff at JADE at their request for random medication counts. When I am requested to bring my medication for a medication count, I agree to allow that medication to be stored by the program staff in a secure place.
    9. I agree not to obtain medications from any doctors, pharmacies, or other sources without telling my treating physician. If I am prescribed another medication, I agree to disclose that information to the physician at JADE Wellness and present the medication at his/her request.
    10. I understand that mixing Buprenorphine with other medication, especially benzodiazepines (for example, Valium**,Klonopin**, or Xanax**) can be dangerous. I also recognize that several deaths have occurred among persons mixing Buprenorphine and benzodiazepines (especially if taken outside the care of a physician, sign routes of administration other than sublingual or in higher than recommended therapeutic doses).
    11. I agree to take my medication as my doctor has instructed and not to alter the way I take my medication in any way.
    12. I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as discussed, agreed upon and specified in my treatment plan.
    13. I agree to abstain from alcohol, opioids, marijuana, cocaine, and other addictive substances (except nicotine)
    14. I agree to provide random urine samples and have my doctor test my blood alcohol level as well as testing for the presence of other drugs. I understand that JADE utilizes third party laborites to conduct qualitative and quantitative drug testing to ensure compliance with both treatment planning and medication management services. I also understand that I may receive an associated bill for the third party services and any cost is my responsibility.
    15. I agree to participated in the development of and compliance with the goals and objectives in my treatment plan.
    16. I understand that violations of the above may be grounds for termination of treatment.
    17.  (For Women Only) Drugs of abuse such as opiates/heroin, cocaine and other stimulants, alcohol, benzodiazepines, nicotine, marijuana, have been shown to have substantial risks during both intoxication and withdrawal to pregnant women and their unborn children. These risks include but are not limited to preterm labor, low birth weight, placental tears or abruption, birth defects, sudden infant death syndrome, and abnormal cognitive/behavioral/motor development.
    18. (For Women Only) If I become pregnant and have history of abusing opiates, I am aware that Subutex maintenance is offered at Jade. I understand that Subutex is transmitted to the unborn child and may result in physical dependency during prenatal stages and postnatal withdrawal.

    Client Responsibilities

    While active in JADE Wellness Center’s 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. Continued No Call/No Sow to scheduled appointments without contacting your CRS or care managemer could result in 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. If your care plan indicates clients will be asked to 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.

    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.

    Emergency and Psychiatric Consents

    I consent to allow JADE 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.

    Hours of Operations

    Monday: 8:30 a.m. - 8:30 p.m.
    Tuesday: 8:30 a.m. - 8:30 p.m.
    Wednesday: 8:30 a.m. - 8:30 p.m.
    thursday: 8:30 a.m. - 8:30 p.m.
    Friday 8:30 a.m. - 5:00 p.m.
    Saturday - By appointment

    *Hours of operation may differ by location 

  • 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.

    If you receive virtual services or have any patient responsibility associated with your account including deductible, co-insurance, copay or you are uninsured, you will be required to put a credit card on file. By providing a credit card you authorize JADE Wellness Center to charge account balances to the credit card on file for services rendered.

    Jade Wellness Center participates in some commercial insurance plans. It is your responsibility to alert us of any changes to your insurance. All insurance related copayments, coinsurance, and deductibles are due at time of service. Should your insurance not cover a service offered by JADE Wellness Center it is your responsibility to cover any cost incurred. We accept all major forms of credit cards, cash and certified checks.

    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 Client 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 and I'm aware that there is a fee schedule posted in the lobby. I have been informed that JADE Wellness Center utilized Pennsylvania's Prescription Drug Monitoring Program and abides by all user general terms and conditions. The use of the PDMP is to prevent prescription drug abuse and protect the health and safety of our community. The information gathered through the PDMP helps JADE Wellness Center and its health care providers safely prescribe controlled substances and helps patients get the treatment they need. Finally, If you are utilizing insurance your demographic information including full name, date of birth, social security will be processed through Electronic Verification Systems including but not limited to: PROMISe/ PA DHS, Navinet, etc.

    JADE Wellness Center sends out urine drug screens for conformation results. It is important to us to ensure that the results indicated onsite (point of care) are in fact accurate. We can send out to one of two companies: LabCorp or Quest diagnostics. These companies have no affiliation with JADE. This means we are not responsible for any bills you receive from these third parties. It is also the policy of JADE Wellness Center for any individual receiving Partial Agonist (Buprenorphine suboxone / chemotherapy services) or Antagonist (ReVia/Vivitrol services) that a minimum of one urine drug screen per month is to be sent out to an external Laboratory for confirmatory results.

    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.

     

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  • 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.

  • PCP/Family Doctor Consent

    Consent & Authorization for the release of information
  • I         Consent for the release and authorization the disclosure and use of my protected health information by JADE Wellness Center, in accordance with federal and/or state law, whichever is more protective of the client's confidentiality, by written copies, facsimile or verbal communication to:

  • I also Understand: 

     

    That regulation 164.508 ensures my right to treatment, payment or enrollment in a health program regardless of whether i sign this authorization, and that i may refuse to sign.

    That when either federal or state laws afford me more stringent level of privacy protection than those regulated by 164.508, JADE Wellness Center will always abide by the more stringent law.

    JADE Wellness Center will only disclose my health infromation gathered through treatment by our internal healthcare clinicians, and will not re-disclose my PHI received from any other external healthcare provider.

    That although Federal Law (42 CFR Part 2) prohibits re-disclosure of your PHI, recipients of your infomration could potentially disregard these and other laws.

    That this authorization expires 30 days after discharge from treatment episode. 

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  • 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.

  • Family Consent and Authorization for the release of information

    Family Consent
  • I         Consent for the release and authorization the disclosure and use of my protected health information by JADE Wellness Center, in accordance with federal and/or state law, whichever is more protective of the client's confidentiality, by written copies, facsimile or verbal communication to:

  • I also understand:

    1. That regulation 164.508 ensures my right to treatment, payment or enrollment in a health program regardless of whether I sign this authorization, and that I may refuse to sign.
    2. That when either federal or state laws afford me more a stringent level of privacy protection than those regulated by 164.508, JADE Wellness Center will always abide by the more stringent law.
    3. JADE Wellness Center will only disclose my health information gathered through treatment by our internal healthcare clinicians, and will not re-disclose my PHI received from any other external healthcare provider.
    4. That although Federal Law (42 CFR Part 2) prohibits re-disclosure of your PHI, recipients of your information could potentially disregard these and other laws.
    5. That this authorization expires 30 days after discharge from treatment episode.
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  • 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.

  • Pharmacy Consent

    Consent & Authorization for the release of information
  • I         Consent for the release and authorization the disclosure and use of my protected health information by JADE Wellness Center, in accordance with federal and/or state law, whichever is more protective of the client's confidentiality, by written copies, facsimile or verbal communication to:

  • I also Understand: 

    1. That regulation 164.508 ensures my right to treatment, payment or enrollment in a health program regardless of whether i sign this authorization, and that i may refuse to sign.
    2. That when either federal or state laws afford me more stringent level of privacy protection than those regulated by 164.508, JADE Wellness Center will always abide by the more stringent law.
    3. JADE Wellness Center will only disclose my health infromation gathered through treatment by our internal healthcare clinicians, and will not re-disclose my PHI received from any other external healthcare provider.
    4. That although Federal Law (42 CFR Part 2) prohibits re-disclosure of your PHI, recipients of your infomration could potentially disregard these and other laws.
    5. That this authorization expires 30 days after discharge from treatment episode. 
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  • 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.

  • Treating Providers, Health Plans, Third Party & People Helping to Operate This Program

    Release of Information
  • I         Consent for the release and authorization the disclosure and use of my protected health information by JADE Wellness Center, in accordance with federal and/or state law, whichever is more protective of the client's confidentiality, by written copies, facsimile or verbal communication to:

  • My treating providers, health plans third-party payers and people helping to operate this program.

  • Purpose of consent: This consent form allows JADE Wellness center to use and disclose your PHI and SUD records only for purposes of treatment, payment and healthcare operations, as required by the health insurance portability and accountability ACT (HIPAA) and 42 CFR Part 2.


    Designated recipient: disclosure of your PHI and SUD records shall be made to your treating providers, health plans, third-party payers, and people helping to operate the jade wellness center program for the following purposes:

    Treatment: You consent to the use and disclosure of your phi and SUD records by JADE Wellness Center for purposes of providing coordinating or managing healthcare and related services. This includes communication with other healthcare providers concerning your treatment.

    Payment: You consent to the use and disclosure of your phi and SUD records as necessary for billing and payment purposes, this includes activities to obtain payment from insurance companies or other third parties, determining eligibility for benefits and collecting outstanding balances

    Healthcare operations: You consent to the use and disclosure of your phi and SUD records for healthcare operations; this includes without limitation quality assessment and improvement activities, reviewing the competence of qualification of healthcare professionals, and conducting training and educational programs.

    I also Understand: 

    1. That regulation 164.508 ensures my right to treatment, payment or enrollment in a health program regardless of whether i sign this authorization, and that i may refuse to sign.
    2. That when either federal or state laws afford me more stringent level of privacy protection than those regulated by 164.508, JADE Wellness Center will always abide by the more stringent law.
    3. JADE Wellness Center will only disclose my health infromation gathered through treatment by our internal healthcare clinicians, and will not re-disclose my PHI received from any other external healthcare provider.
    4. That although Federal Law (42 CFR Part 2) prohibits re-disclosure of your PHI, recipients of your infomration could potentially disregard these and other laws.
    5. That this authorization expires 30 days after discharge from treatment episode. 
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  • 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.

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