{name31}

 

ADULT ADHD SELF-REPORT SCALE (ASRS-VI.1) SYMPTOM CHECKLIST

 

Telehealth Appointment Consent Form

I, {name31} , hereby consent to engage in Telehealth with CLENDENIN MD.

Telehealth is the use of the Internet to provide remote health care for patients. Such care may come from doctors, nurses, mental health providers, and professional health educators.

Specifically, a health care professional will be communicating with me remotely via the Internet using ZOOM web-based audio-video software (referred to in this form as Telehealth Appointment). ZOOM only hosts the software and does not provide medical advice or information.

This Telehealth Appointment may be for diagnosis, continuity of care, treatment, testing, or medical consultation deemed necessary by my Healthcare Provider or me.

I understand that during a Telehealth Appointment

• Details of my medical history and personal health information may be discussed with me and/or other health professionals;
• Audio, video, or photo recordings containing medical details may be transmitted via secure channels and those details may become part of my permanent medical record;
• All confidentiality protections granted to me by various state and federal laws also apply to my care during this appointment;
• Industry-standard network and software security protocols are in place that protect the privacy of the communication and safeguard my transmitted information against eavesdropping and corruption;
• There may be security and privacy risks associated with Internet-based communications;
• There are benefits and limitations when compared to a traditional in-person visit due to the fact that I will not be in the same room as my healthcare provider;
• Either my Healthcare Provider or I can discontinue the Telehealth Appointment if either of us feels that the information obtained through remote communications is not adequate for diagnostic
  decision-making or for providing the care I desire;
• In addition to my Healthcare Provider named above, I will be informed of any other person(s) who may be present during the appointment and have the right to have them leave the viewing and listening area;
• To maintain my privacy, I need to ensure that my viewing and listening area is limited to myself and any other person that has a need to participate during the virtual appointment;
• Due to the limitations of telehealth that are out of my control (such as an unreliable internet connection), I will call local authorities (9-1-1) to assist me with a medical emergency;
• I have the right to omit or withhold specific details of my medical history/physical examination that are personally sensitive;
• My Healthcare Provider may advise me to seek immediate treatment or determine that there is a medical emergency and, as such, local authorities may be given my personal details to assist me;
• The communication is privileged and confidential, and I will not record the audio or video without first seeking the permission of my Healthcare Provider.

Therefore, by consenting to this Telehealth Appointment:

1. I desire to engage in remote audio-visual communication with my Healthcare Provider.
2. I understand the risks and benefits of using Internet-based communications and that no results can be guaranteed.
3. I acknowledge that if the Healthcare Provider believes that remote communication is insufficient for treatment, consultation, or evaluation, then I will be offered alternate services or options.
4. I understand that I may be responsible for co-payments, deductibles, or other charges from my Healthcare Provider, and additional charges may occur for services related to this appointment.
5. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Healthcare Provider.
6. I have the ability to ask direct questions to my Healthcare Provider about this appointment, including details about the Healthcare Provider's privacy policy.
7. If my questions are not answered to my satisfaction, I have the right to terminate the appointment.
8. I am at least 18 years of age.

 

CONTROLLED SUBSTANCES AGREEMENT

 

I, {name31} , a patient of CLENDENIN MD, have been informed that individuals who are prescribed certain controlled substances including, but not limited to, narcotic pain medicines, stimulants, benzodiazepine tranquilizers, and barbiturate sedatives, can abuse those substances or may allow abuse by others, and have some risk of developing an addictive disorder or suffering a relapse of a prior addiction. Therefore, I have been informed that it is necessary to observe strict rules pertaining to their use, and I agree to follow the terms and procedures described in this Agreement as consideration for, and as a condition of, the willingness of the physician whose signature appears below to consider prescribing or to continue prescribing controlled substances to treat my condition.

 

1. I will inform my provider of any current or past substance abuse, or any current or past substance abuse of any immediate member of my immediate family.

2. I agree that I may be subject to a voluntary evaluation by psychologists and/or psychiatrists, possibly at my own expense, before any controlled substances will be prescribed to me. I agree that the need to be evaluated by psychologists and/or psychiatrists may be revisited every three (3) to six (6) months thereafter while taking the medication.

3. All controlled substances must come from a prescribing provider in CLENDENIN MD's virtual office. My controlled substances will come from the prescribing provider whose signature appears below, or during his or her absence, by the covering provider, unless specific written authorization is obtained from the office for an exception.

4. I will obtain all controlled substances from the same pharmacy. Should the need arise to change pharmacies, I will inform the CLENDENIN MD's office.

5. I will inform the CLENDENIN MD's office of any new medications or medical conditions, and of any adverse effects I experience from any of the medications that I take.

6. I will inform my other health care providers that I am taking the controlled substances listed above, and of the existence of this Agreement. In the event of an emergency, I will provide the foregoing information to emergency department providers.

7. I agree that my prescribing provider has permission to discuss all diagnostic and treatment details with other health care providers, pharmacists, or other professionals who provide my health care regarding my use of controlled substances for purposes of maintaining accountability.

8. I will not allow anyone else to have, use, sell, or otherwise have access to these medications. The sharing of medications with anyone is absolutely forbidden and is against the law.

9. I understand that controlled substances may be hazardous or lethal to a person who is not tolerant to their effects, especially a child, and that I must keep them out of reach of such people for their own safety.

10.I understand that tampering with a written prescription is a felony and I will not change or tamper with my doctor's written

11. I am aware that attempting to obtain a controlled substance under false pretenses is illegal.

12. I agree not to alter my medication in any way, and I will take my medication whole, and it will not be broken, chewed, crushed, injected, or snorted.

13. I will take my medication as instructed and prescribed, and I will not exceed the maximum prescribed dose. Any change in dosage must be approved by a CLENDENIN MD's prescribing provider.

14. I understand that these drugs should not be stopped abruptly, as withdrawal syndromes may develop.

15. I will cooperate with unannounced urine or serum toxicology screenings as may be requested, as well as any random pill counts of medication by CLENDENIN MD. Failure to comply may result in immediate discharge from the practice.

16. I understand that the presence of unauthorized and/or illegal substances in the screenings described in the paragraph above may prompt referral for assessment for a substance abuse disorder or discharge from the practice.

17. I understand that medications may not be replaced if they are lost, damaged, or stolen. If any of these situations arise that cause me to request an early refill of my medication, a copy of a filed police report or a statement from me explaining the circumstances may be required before additional prescriptions are considered. If I request an early refill secondary to lost, damaged, or stolen prescriptions twice within a year, I may be discharged from the practice.

18. I understand that a prescription may be given early if the physician or the patient will be out of town when the refill is due. These prescriptions will contain instructions to the pharmacist that the prescriptions(s) may not be filled prior to the appropriate date.

19. If the responsible legal authorities have questions concerning my treatment, as may occur, for example, if I obtained medication at several pharmacies, all confidentiality is waived, and these authorities may be given full access to my full records of controlled substances administration.

20. I will keep my scheduled appointments in order to receive medication renewals. If I need to cancel my appointment, I will do SO a minimum of twenty-four (24) hours before it is scheduled.

21. I understand that I may be asked to bring or show my medications in their original container to the CLENDENIN MD's virtual office

while I am on controlled medication.

22. Refills generally will not be given over the phone, after office hours, during the weekends, and on holidays.

23. I understand that any medical treatment is initially a trial, with the goal of treatment being to improve the quality of life and ability to function and/or work. These parameters will be assessed periodically to determine the benefits of continued therapy, and continued prescription is contingent on whether my prescribing provider believes that the medication usage benefits me. I will comply with all treatments as outlined by my provider at CLENDENIN MD.

24.I have been explained the risks and potential benefits of these

therapies, including, but not limited to, psychological addiction, physical dependence, withdrawal and overdose.

25. I understand that failure to adhere to these policies and/or failure to comply with prescribing provider's treatment plan may result in cessation of therapy with controlled substance prescribing by this provider or referral for further specialty assessment, as well as possible discharge from the practice.

26. I, the undersigned patient, attest that the foregoing was discussed with me, and that I have read, fully understand, and agree to all of the above requirements and instructions. I affirm that I have the full right and power to sign and be bound by this Agreement.

1.) I understand that my payment is non-refundable once processed.

• My payment secures an appointment and Dr. Clendenin's availability for the agreed-upon telemedicine session.
• I acknowledge that the service is considered fully rendered after payment, regardless of whether I attend or complete the session.

 2.) I agree that no refunds, chargebacks, or disputes will be permitted after payment.

• I understand that Dr. Clendenin commits time to my consultation once the payment is processed.
• I agree not to dispute or challenge the charge with my bank, credit card company, or payment provider, as the payment is final.

3.) I acknowledge that refunds are only available under specific conditions.

• A refund will only be provided if Dr. Clendenin is unable to meet or fulfill the scheduled telemedicine appointment due to reasons beyond my control.
• I understand that if rescheduling is possible, I will be offered an alternative time. Only if rescheduling is not feasible will a refund be processed.

• By checking this box, I confirm my complete agreement with the terms outlined above.

{name31}

1. General Consent to Treat

I hereby consent to treatment by licensed medical Providers affiliated with CLENDENIN MD. I understand that all services are delivered via telemedicine, including evaluation, diagnosis, and treatment of my medical condition. I acknowledge that telemedicine involves electronic communication and I consent to receive treatment in this format.

2. HIPAA Acknowledgment and Privacy Practices

I acknowledge that I have reviewed the Notice of Privacy Practices for CLENDENIN MD. I understand how my medical information may be used and disclosed, and how I can access this information.

3. Financial Policy Agreement

I agree to the financial policies of CLENDENIN MD. I understand that payments for consultations are due in full prior to the visit. I understand that the consultation fee covers the Provider’s time and expertise and does not guarantee a prescription. I am responsible for payment of services.

4. Identity and Insurance Verification Consent

I authorize CLENDENIN MD to verify my identity and insurance information. I agree to provide valid identification and any required documentation before receiving services.

5. Informed Consent for Medication

I consent to the prescription of medications when clinically appropriate, including controlled substances such as Ketamine, Suboxone, Adderall, and Testosterone. I understand the risks, benefits, and alternatives to these treatments, and I agree to follow the treatment plan as prescribed by my Provider.

6. Controlled Substance Agreement

I understand that Ketamine, Suboxone, Adderall, and Testosterone are controlled substances. I agree to comply with federal and state laws, submit to random drug screenings as required and not share or misuse my medications. I understand that any noncompliance may result in discontinuation of treatment.

7. Telemedicine Consent Form

I consent to receive medical care via telemedicine. I understand that I will not receive in-person physical exams and that telemedicine has limitations. I accept the risks involved and agree to proceed with care via secure video or audio platforms.

8. Ketamine Consent and Waiver

If I participate in in a Ketamine treatment program, I consent to receive Ketamine-assisted treatment as prescribed by a licensed Provider. I understand the dissociative effects, possible side effects, and off-label use for depression or chronic pain. I agree to remain in a safe environment during treatment and to follow post-treatment recommendations.

9. Psychotherapy Informed Consent

If psychotherapy is part of my treatment, I consent to participate in sessions delivered via telemedicine. I understand the structure, confidentiality limits, and my rights as a client.

10. Arbitration Agreement

I agree to resolve any legal disputes with CLENDENIN MD through binding arbitration rather than court litigation. This agreement covers all services received via telemedicine.

11. No-Show and Late Cancellation Policy

I understand that if I miss a scheduled appointment or is 10 minutes late without a prior notice at least 3 hours before my appointment, I will be charged a $25 service charge to reschedule. Repeated no-shows may result in discharge from the practice.

12. Electronic Communication Consent

I consent to communication via email, text, and telemedicine platforms. I understand the risks of unsecured communication and agree to use secure portals where available.

13. Photo and Video Consent

I consent to the use of video for telemedicine visits. I understand that these sessions may be recorded only with my explicit permission for clinical or training purposes.

14. Patient Code of Conduct

I agree to engage respectfully with all Staff and Providers at CLENDENIN MD. Harassment, abuse, or threatening behavior may result in termination of care.

 

15. Termination of Care Policy Acknowledgment

I understand that CLENDENIN MD reserves the right to discontinue care due to noncompliance, unsafe behavior, policy violations or any medical care not well-suited for telemedicine determined by the Provider.. I will be notified in writing of any such decision.

16. Program Commitment Agreement

If I participate in a treatment program involving Ketamine, Suboxone, Adderall, or Testosterone, I agree to attend follow-ups, complete required labs, and adhere to the medication protocol outlined by my Provider.

Clendenin MD requires all of our ADHD patients to undergo QbChecks by remote testing. Additional fee of $149 will be charged. This test is FDA-cleared and reimbursable by many insurance companies. A Superbill will be forthcoming upon completion & assessment of the test.

Providing previous QbCheck test or documentation confirming ADHD diagnosis by previous providers will waived the need to take the initial test.