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</u></b>I understand that I am obligated to pay the account of the ANR Clinic in accordance with the regular rates and
terms of the Clinic. If I fail to make payment when due and the account becomes delinquent or is turned over to a
collection agency or an attorney for collection, I agree to pay all collection agency fees, court costs and attorney’s
fees. I also agree that any patient or guarantor overpayments on the above Clinic visit may be applied directly to
any delinquent account for which I or my guarantor is legally responsible at the time of the collection of the
overpayment.
</p><p><b><u>2. PATIENT CONSENT FOR E-PRESCRIBING (ELECTRONIC PRESCRIBING):</u></b>
I have been made aware and understand that the medical practices and offices may use an electronic
prescription system which allows prescriptions and related information to be electronically sent between my
providers and my pharmacy. I have been informed and understand that my providers using the electronic
prescribing system will be able to see information about medications I am already taking, including those
prescribed by other providers. I give my consent to my providers to see this protected health information.
</p><p><b><u>3. CONSENT TO RELEASE HEALTH INFORMATION:</u></b>
I understand this Clinic uses an electronic medical record. I understand that the electronic medical record
contains information about my health from my past, current and future health care providers. I agree that this
health information may be released through the Clinic’s electronic medical record or by other means (for
example, fax, telephone, email, or hand delivery): (1) to the Clinic; (2) to my past, current and future health care
providers and other health care organizations that provide care to me; and (3) to any other person named in my
medical record who pays for my treatment. These people may use my health information: (1) to treat me; (2) to
get paid for my treatment, and (3) to do health care operations activities (for example, managing my care,
providing quality care, patient safety activities, and other activities necessary to run the Clinic). I understand that
these people will have access to all my health information in the medical record, including behavioral health and
substance use disorder information (for example, drug and alcohol treatment), my medical history, diagnosis,
hospital records, clinic and doctor visit information, medications, allergies, lab test results, radiology reports,
sexual and reproductive health information, communicable disease- related information (for example, sexually
transmitted diseases), and HIV/AIDS-related information. I understand that I may take back this consent at any
time, except if my health information has already been released to someone. I also understand that I may
request a list of the health care organizations that have received my substance use disorder information. This
consent will expire one year after my death.
</p><p><b><u>4. NOTICE OF PRIVACY PRACTICES:</u></b>
Required pursuant to Health Insurance Portability and Accountability Act of 1996 (HIPAA), I acknowledge that I
have received a copy of the ANR Clinic’s Notice of Privacy Practices. I hereby consent to the use and
disclosure of my protected health information, including information generated through use of virtual health or
telemedicine services, as described in the Notice of Privacy Practices. This will include all of my protected health
information generated during hospitalization and outpatient treatment at the Clinic, including but not limited to
treatment for mental health, drug and alcohol abuse, communicable diseases such as HIV/AIDS, developmental
disabilities, genetic testing, and other types of treatment received.
</p><p><b><u>5. GENERAL CONSENT FOR TESTS, TREATMENT, AND SERVICES:</u></b>
I have been informed of the treatment procedures considered necessary for me and that the treatments/
procedures will be directed by a physician or independent Advanced Practitioner, in accordance with state laws,
scope of practice, and licensure of medical staff.
</p><p><b><u>6. CONSENT FOR VIRTUAL HEALTH/TELEMEDICINE SERVICES:</u></b>
I hereby consent to engaging in virtual health or telemedicine services, where available, as part of my treatment. I
understand that “virtual health” or “telemedicine services” includes the practice of health care delivery, diagnosis,
consultation, treatment, transfers of medical data, and education using interactive audio, video, or data
communications when the health care provider and patient are not in the same physical location.
The interactive electronic systems used for these services will incorporate network and software security
protocols to protect the confidentiality of patient identification and imaging data and will include measures to
safeguard the data to ensure its integrity against intentional or unintentional corruption. I understand that the
potential benefits of receiving care in this manner include improved access to care and the ability to obtain
the expertise of a distant specialist. The potential risks include problems with information transmittal, including
but not limited to poor data transfer which may include a poor video and data quality experience, or lack of
access to my complete medical record by the remote physician. I understand that all information, including
images, will be part of my medical record available to me if requested and with the same restrictions on
dissemination without my consent. I understand I may withdraw my consent at any time.&nbsp;<br></p>";s:15:"container_class";s:0:"";s:13:"element_class";s:0:"";s:3:"key";s:18:"html_1595377208202";s:14:"drawerDisabled";b:0;}}s:5:"tmp-2";a:1:{s:8:"settings";a:10:{s:10:"objectType";s:5:"Field";s:12:"objectDomain";s:6:"fields";s:10:"editActive";b:0;s:5:"order";i:9999;s:4:"type";s:6:"submit";s:5:"label";s:6:"Submit";s:16:"processing_label";s:10:"Processing";s:15:"container_class";s:0:"";s:13:"element_class";s:0:"";s:3:"key";s:20:"submit_1595377330903";}}}s:7:"actions";a:3:{s:5:"tmp-1";a:1:{s:8:"settings";a:28:{s:10:"objectType";s:6:"Action";s:12:"objectDomain";s:7:"actions";s:10:"editActive";b:0;s:5:"label";s:15:"Success Message";s:4:"type";s:14:"successmessage";s:7:"message";s:42:"Your form has been successfully submitted.";s:5:"order";i:1;s:6:"active";b:1;s:16:"payment_gateways";s:0:"";s:13:"payment_total";s:1:"0";s:3:"tag";s:0:"";s:2:"to";s:16:"{wp:admin_email}";s:8:"reply_to";s:0:"";s:13:"email_subject";s:22:"Ninja Forms Submission";s:13:"email_message";s:14:"{fields_table}";s:19:"email_message_plain";s:0:"";s:9:"from_name";s:0:"";s:12:"from_address";s:0:"";s:12:"email_format";s:4:"html";s:2:"cc";s:0:"";s:3:"bcc";s:0:"";s:12:"redirect_url";s:0:"";s:15:"submitter_email";s:0:"";s:18:"fields-save-toggle";s:8:"save_all";s:16:"exception_fields";a:0:{}s:18:"set_subs_to_expire";i:0;s:16:"subs_expire_time";s:2:"90";s:11:"success_msg";s:42:"Your form has been successfully submitted.";}}s:5:"tmp-2";a:1:{s:8:"settings";a:21:{s:10:"objectType";s:6:"Action";s:12:"objectDomain";s:7:"actions";s:10:"editActive";b:0;s:5:"label";s:11:"Admin Email";s:4:"type";s:5:"email";s:5:"order";i:2;s:6:"active";b:1;s:7:"message";s:170:"This action adds users to WordPress&#039; personal data delete tool, allowing admins to comply with the GDPR and other privacy regulations from the site&#039;s front end.";s:16:"payment_gateways";s:0:"";s:13:"payment_total";s:1:"0";s:3:"tag";s:0:"";s:2:"to";s:16:"{wp:admin_email}";s:8:"reply_to";s:0:"";s:13:"email_subject";s:22:"Ninja Forms Submission";s:13:"email_message";s:14:"{fields_table}";s:19:"email_message_plain";s:0:"";s:9:"from_name";s:0:"";s:12:"from_address";s:0:"";s:12:"email_format";s:4:"html";s:2:"cc";s:0:"";s:3:"bcc";s:0:"";}}s:5:"tmp-3";a:1:{s:8:"settings";a:27:{s:10:"objectType";s:6:"Action";s:12:"objectDomain";s:7:"actions";s:10:"editActive";b:0;s:5:"label";s:16:"Store Submission";s:4:"type";s:4:"save";s:5:"order";i:3;s:6:"active";b:1;s:7:"message";s:170:"This action adds users to WordPress&#039; personal data export tool, allowing admins to comply with the GDPR and other privacy regulations from the site&#039;s front end.";s:16:"payment_gateways";s:0:"";s:13:"payment_total";s:1:"0";s:3:"tag";s:0:"";s:2:"to";s:16:"{wp:admin_email}";s:8:"reply_to";s:0:"";s:13:"email_subject";s:22:"Ninja Forms Submission";s:13:"email_message";s:14:"{fields_table}";s:19:"email_message_plain";s:0:"";s:9:"from_name";s:0:"";s:12:"from_address";s:0:"";s:12:"email_format";s:4:"html";s:2:"cc";s:0:"";s:3:"bcc";s:0:"";s:12:"redirect_url";s:0:"";s:15:"submitter_email";s:0:"";s:18:"fields-save-toggle";s:8:"save_all";s:16:"exception_fields";a:0:{}s:18:"set_subs_to_expire";i:0;s:16:"subs_expire_time";s:2:"90";}}}}