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* 1. I, (patient identified above), voluntarily request to receive medical treatment from Assisted Recover Centers of America (ARCA). I understand that this consent is for any of the services or programs which are provided by ARCA.
I consent to the administration of treatment deemed necessary by my provider(s) who attend to me, their associates, employees of ARCA, and any other healthcare professionals responsible for my care. I understand that care may consist of a physical exam, medical assessment, nursing and counseling/social work assessments, laboratory tests, treatment planning, individual and group treatments, discharge planning, care coordination, as well as prescribing and administration of medications.
The purpose of my participation in treatment has been described to me. I understand that the specific care proposed for me, including the benefits and risks, may be further discussed with me by my provider, nursing or counseling staff. I agree to attend and participate in all scheduled treatment activities as described in my treatment/services plan. I understand that I have the right to ask for clarification of services and interventions and to decline the services and interventions at any time. I acknowledge that no guarantees have been made to me as to the effect of treatment or prognosis of my condition.
I understand that in the event of an emergency, I may be transferred to a hospital or emergency medical facility better equipped than ARCA to provide emergency and/or comprehensive medical care.

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* 2.
I understand that my express consent is required to release any health care information relating to testing, diagnosis, medications and or treatment for psychiatric disorders or drug/alcohol abuse/dependence. I give my consent for ARCA to release medical including information for psychiatric and or drug/alcohol abuse/dependence.

I give my consent for ARCA to release medical including information for psychiatric and or drug/alcohol abuse or dependence and other relevant information as required by my insurance company to process medical billing. I authorize direct payment to ARCA of all insurance benefits applicable to this episode of care which are now or which shall become due and payable to me.

In addition, I authorize direct payment to the company of all insurance benefits applicable to medical services rendered by providers for whom ARCA is authorized to charge and bill. I understand that ARCA works with providers who are independent contractors. I consent to the assignment of benefits and release of information stated above as it may pertain to those independent contractors.

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* 3. In accordance with the above terms in consideration of the service rendered to the patient designated herein, I guarantee and agree to pay ARCA charges for those services rendered, including any deductibles, co-insurance or amounts not paid by my Insurance plan, health service plan or health maintenance organization.

By singing this document, the patient and guarantors acknowledge and agree they are responsible for payment of billed charges rendered in any case in which payment may be denied by the health maintenance organization (or preferred provider organization), or other insurance provider.

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* 4. We are required by law to maintain the privacy and confidentiality of information about your health, health care, and payment for services related to your health (referred to in this notice as "protected health information"), and to provide you with this notice of our legal duties and privacy practices with respect to your protected health information. When we use, or disclose this information, we are required to abide by the terms of this notice
Protected Health Information (PHI) in connection with alcohol or drug services: 42 CFR Part 2 protects your health information if you are applying or receiving treatment services for alcohol or drugs. This includes protecting diagnosis, treatment, or referrals related to alcohol or drug treatment. Generally, if you are applying for or receiving services for drugs or alcohol, we may not acknowledge to a person outside of ARCA that you are receiving services from our partner program, except under certain circumstances that are listed in this notice.

All PHI, including alcohol or drug services: the Health Insurance Portability and Accountability Act ("HIPAA") Privacy Regulations (45 CFR Parts 160 and 164), also protect your health information whether or not you are applying for or receiving services for drugs or alcohol. Generally, if you are receiving services that are not related to alcohol or drugs, the laws regulating disclosure of protected health information differ slightly and is less restrictive. Since our treatment at ARCA is specifically for alcohol or drugs, we follow the stricter rules, as stated in 42 CFR, which also satisfies HIPAA standards.

Generally, we may use or disclose formation when you give your authorization to do so in writing on a form that specifically meets the requirements of laws and regulations that apply.

There are some expectations and special rules that allow for uses and disclosures without your authorization or consent. They are listed in this notice.

You may revoke your authorization except to the extend that we have already taken action upon the authorization. If you are currently receiving care and wish to revoke your authorization, you will need to deliver a written statement to an ARCA staff member. If you wish to revoke authorization after discharging, you can send us a written notice of your revocation to 6651 Chippewa, Suite 224, Saint Louis, MO 63109.

Even when you have not given your written authorization, we may use and disclose information under the circumstances listed below. This list applies to all protected health information, including the information we get when you are applying for or receiving services for drugs or alcohol.

We may use or disclose your PHI for treatment purposes among staff at ARCA. Treatment includes diagnosis, treatment and other services, including discharge planning. For example, therapists may disclose your health information to each other or to nursing staff to coordinate your treatment, improve treatment, or discuss treatment alternatives.

We may use or disclose your PHI for the purposes of health care operations that include internal administration, planning and various activities that improve the quality and effectiveness of care. E.g., we may use information about your care to internally evaluate the quality and competence of our staff. In any case, ARCA staff would continue to maintain your privacy and confidentiality as a person who received services at ARCA.

We may disclose your protected health information to medical personnel to the extent necessary to ensure your safety in a medical emergency (as defined by 42 CFR part 2).

We may disclose your PHI in response to a court order that meets the requirements of federal regulations, 42 CFR Part 2 concerning Confidentiality of Alcohol and Drug Abuse Patient Records.

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* 5. Commission of a Crime on Premises or against ARCA staff or other building staff: We may disclose your PHI to the police or other law enforcement officials if you commit a crime on the premises or against staff, or if you threaten to do so.

We may disclose your PHI for the purpose of reporting child or elder abuse and neglect to the appropriate authorities for abuse reporting.

When the program learns that a patient has made a specific threat of serious physical harm to another specific person or the public, and disclosure is otherwise required under statute/or common law, the program will carefully consider appropriate options that would permit disclosure.

We may disclose PHI to those who perform audits or evaluation activities for certain health oversight agencies, e.g. state licensure or certification agencies, the Joint Commission on Accreditation of Health Care Organization, which oversees the health care system & ensures compliance with regulations and standards.

You may request additional restrictions on our use and disclosure of PHI for treatment, payment and health care operations. While we consider requests for additional restrictions carefully, we are not required to agree to a requested restriction. If you wish to request additional restriction and you are currently receiving services, you may contact us in writing to request restrictions. We will send you a written response.

You may request access to your clinical file and billing records maintained by us in order to inspect and request copies of the records. Under limited circumstances, we may deny you access to a portion of your records. If you desire access to your records and you are currently receiving services, you can contact ARCA directly in writing. If you request copies, there will be a charge for each page copied. The cost will be disclosed prior to print.

You have the right to request that we amend protected health information maintained in your clinical file or billing records. If you desire to amend your records and you are currently receiving services, please contact your therapist or counselor. Once you are no longer receiving services, you may request an amendment to your records in writing.

Under certain circumstances, ARCA has the right to deny your request to amend your records and will notify you of this denial as provided in the HIPAA regulations. If your requested amendment to your records is accepted, a copy of your amendment will become a permanent part of the medical record. When we "amend" a record, we may append information to the original record, as opposed to physically removing or changing the original record. If your requested amendment is denied, you will be informed of your right to have a brief statement of disagreement placed in your medical records.

Upon request, you may obtain a list of instances that we have disclosed your PHI other than when you gave written authorization OR those related to your treatment and payment for services, or our health care operations.

The accounting will apply only to covered disclosures prior to the date of your request provided such period does not exceed six years. If you request an accounting more than once during a 12 month period, there will be a charge. You will be told the cost prior to the request being filled.

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* 6. Upon request, you may obtain a paper copy of this notice.

If you desire further information about your privacy and confidentiality rights, you may contact the ARCA Executive Director at (314) 645-6840 ext. 3757. You may call this number if you are concerned that we have violated your privacy rights, if you disagree with a decision that we made about access to your protected health information, or if you wish to complain about our breach notification process.

You may also file a written complaint with the Secretary of the United Stated Department of Health and Human Services. Upon request, we will provide you with the correct address. We will not retaliate against you if you file a complaint.

Violation of federal law and regulations on Confidentiality of Alcohol and Drug Abuse Patient Records is a crime and suspected violations of 42 CFR Part 2 may be reported to the United States Attorney in the district where the violation occurs.

Effective Date: May 20, 2013

We may change the terms of this notice at any time. If we change this notice, we may make the new notice terms effective to all PHI that we maintain, including any information created or received prior to issuing the new notice.

We may change the terms of this notice at any time. If we change this notice, we may make the new notice terms effective to all PHI that we maintain, including any information created or received prior to issuing the new notice.

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* 7. Telemedicine Services.
I hereby request, consent and authorize VSee and its subsidiaries, affiliates, representatives, and agents (collectively, “VSee”) and their employed or contracted physicians, physician assistants, nurse practitioners or other licensed health care professionals in its care network (the “Practitioners”), to utilize telemedicine through VSee’s proprietary systems, methods and protocols to access, diagnose, consult, treat and educate me and those I am authorized to represent (the “Services”).

I acknowledge and consent to see a Practitioner via telemedicine. I understand that my eligibility to receive a visit via telemedicine is based on the Practitioner’s medical judgment that it is appropriate and that the quality of care will not be diminished by the use of telemedicine. I understand that a telemedicine visit is distinct from an in-person visit because I will not be in the same room as the health care Practitioner, and instead, I will communicate with the Practitioner through advanced communication technology using live video and audio feed. 

I acknowledge that in order to protect my privacy, I need to choose a private location to place my telemedicine call.  I understand that in order to provide the best call environment, I should reduce background light from windows or light emanating from behind me. I understand that my camera should be placed on a secure, stable platform to avoid wobbling and shaking during the telemedicine session. To the extent possible, my camera should be placed at the same elevation as my eyes with my face clearly visible to the other person.  I understand that I will be informed of the presence of any third party, including those that may be present to assist with the audio or video equipment, and that I have the right to: (1) omit specific details of medical history or physical examination that are sensitive to me during such third party presence, (2) ask non-medical personnel to leave the telemedicine examination room, and/or (3) terminate the consultation at any time by notifying the Practitioner or disconnecting from the telemedicine portal.

I understand the potential risks of receiving the Services via telemedicine include: delays in medical evaluation due to technological equipment failure, a lack of access to all relevant information, or a security breach allowing unauthorized access to my confidential medical information. I understand that my Practitioner or I may terminate the telemedicine visit at any time, including if the Practitioner or I feel that an in-person visit is necessary for any reason. I have had the Services and alternatives to telemedicine for my Services explained to me and I choose to and continue with a telemedicine visit.

I understand that any complaint may be filed with the Secretary of the Department of Health and Human Services.

I have read and understood the written information provided above. I agree that the information provided above adequately explains the Services, along with the risks and benefits to me of said Services. I have had the opportunity to ask questions about this information – if I had any questions, all of my questions have been answered in full. By electronically signing this form, I acknowledge and agree to all of the above, and certify that I have no questions and/or have had my questions answered in full.

By electronically signing this informed consent, I am agreeing to conduct transactions electronically, and intend for my electronic signature to be a binding electronic signature on myself and those I am authorized to represent. Further, I understand and acknowledge that I am digitally receiving a copy of this Agreement concurrently upon execution to print and/or retain a copy of this Agreement, and may also request a paper copy from VSee using the contact information below:

If you have any questions, please contact

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* 8. Type in your full name as digital consent that you have read and understand the previous statements. 

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