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<p><b><u>1. PROMISE TO PAY:<br />
</u></b>I understand that I am obligated to pay the account of the ANR Clinic in accordance with the regular rates and<br />
terms of the Clinic. If I fail to make payment when due and the account becomes delinquent or is turned over to a<br />
collection agency or an attorney for collection, I agree to pay all collection agency fees, court costs and attorney’s<br />
fees. I also agree that any patient or guarantor overpayments on the above Clinic visit may be applied directly to<br />
any delinquent account for which I or my guarantor is legally responsible at the time of the collection of the<br />
overpayment.<br /><b><u>2. PATIENT CONSENT FOR E-PRESCRIBING (ELECTRONIC PRESCRIBING):</u></b><br />
I have been made aware and understand that the medical practices and offices may use an electronic<br />
prescription system which allows prescriptions and related information to be electronically sent between my<br />
providers and my pharmacy. I have been informed and understand that my providers using the electronic<br />
prescribing system will be able to see information about medications I am already taking, including those<br />
prescribed by other providers. I give my consent to my providers to see this protected health information.<br /><b><u>3. CONSENT TO RELEASE HEALTH INFORMATION:</u></b><br />
I understand this Clinic uses an electronic medical record. I understand that the electronic medical record<br />
contains information about my health from my past, current and future health care providers. I agree that this<br />
health information may be released through the Clinic’s electronic medical record or by other means (for<br />
example, fax, telephone, email, or hand delivery): (1) to the Clinic; (2) to my past, current and future health care<br />
providers and other health care organizations that provide care to me; and (3) to any other person named in my<br />
medical record who pays for my treatment. These people may use my health information: (1) to treat me; (2) to<br />
get paid for my treatment, and (3) to do health care operations activities (for example, managing my care,<br />
providing quality care, patient safety activities, and other activities necessary to run the Clinic). I understand that<br />
these people will have access to all my health information in the medical record, including behavioral health and<br />
substance use disorder information (for example, drug and alcohol treatment), my medical history, diagnosis,<br />
hospital records, clinic and doctor visit information, medications, allergies, lab test results, radiology reports,<br />
sexual and reproductive health information, communicable disease- related information (for example, sexually<br />
transmitted diseases), and HIV/AIDS-related information. I understand that I may take back this consent at any<br />
time, except if my health information has already been released to someone. I also understand that I may<br />
request a list of the health care organizations that have received my substance use disorder information. This<br />
consent will expire one year after my death.<br /><b><u>4. NOTICE OF PRIVACY PRACTICES:</u></b><br />
Required pursuant to Health Insurance Portability and Accountability Act of 1996 (HIPAA), I acknowledge that I<br />
have received a copy of the ANR Clinic’s Notice of Privacy Practices. I hereby consent to the use and<br />
disclosure of my protected health information, including information generated through use of virtual health or<br />
telemedicine services, as described in the Notice of Privacy Practices. This will include all of my protected health<br />
information generated during hospitalization and outpatient treatment at the Clinic, including but not limited to<br />
treatment for mental health, drug and alcohol abuse, communicable diseases such as HIV/AIDS, developmental<br />
disabilities, genetic testing, and other types of treatment received.<br /><b><u>5. GENERAL CONSENT FOR TESTS, TREATMENT, AND SERVICES:</u></b><br />
I have been informed of the treatment procedures considered necessary for me and that the treatments/<br />
procedures will be directed by a physician or independent Advanced Practitioner, in accordance with state laws,<br />
scope of practice, and licensure of medical staff.</p>
<p><b><u>6. CONSENT FOR VIRTUAL HEALTH/TELEMEDICINE SERVICES:</u></b><br />
I hereby consent to engaging in virtual health or telemedicine services, where available, as part of my treatment. I<br />
understand that “virtual health” or “telemedicine services” includes the practice of health care delivery, diagnosis,<br />
consultation, treatment, transfers of medical data, and education using interactive audio, video, or data<br />
communications when the health care provider and patient are not in the same physical location.<br />
The interactive electronic systems used for these services will incorporate network and software security<br />
protocols to protect the confidentiality of patient identification and imaging data and will include measures to<br />
safeguard the data to ensure its integrity against intentional or unintentional corruption. I understand that the<br />
potential benefits of receiving care in this manner include improved access to care and the ability to obtain<br />
the expertise of a distant specialist. The potential risks include problems with information transmittal, including<br />
but not limited to poor data transfer which may include a poor video and data quality experience, or lack of<br />
access to my complete medical record by the remote physician. I understand that all information, including<br />
images, will be part of my medical record available to me if requested and with the same restrictions on<br />
dissemination without my consent. I understand I may withdraw my consent at any time.&nbsp;</p>
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<p><b><u>7. ADVANCE DIRECTIVE ACKNOWLEDGEMENT:<br />
</u></b>Federal law requires that patients be provided information about their rights to make advance health care<br />
decisions, including Living Will, Durable Medical Power of Attorney or designation of surrogate decision made for<br />
health care decisions. If you have already completed any of these documents, please inform your physician and<br />
the Clinic.</p>
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<td valign="top">Please Select One:</td>
<td>I have executed an advance directive and have supplied a copy to the Clinic.</td>
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<p><b><u>8. RESEARCH STUDIES:</u></b></p>
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<td valign="top">Are you currently a participant in any research study or project?:</td>
<td>No</td>
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<td valign="top">If yes, please briefly describe what is being studied.:</td>
<td>test</td>
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<td valign="top">Who can the Clinic contact with questions about the Study?:</td>
<td>tresdt</td>
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<p><u><b>9. CONSENT TO PHOTO/VIDEO:</b></u><br />
I consent to the photographing, videotaping and/or video monitoring, including appropriate portions of my<br />
body, for medical and medical record documentation purposes, provided said photographs or videotapes are<br />
maintained and released in accordance with protected health information regulations.<br /><u><b>10. CONSENT TO PHOTOGRAPH AT THE TIME OF REGISTRATION:</b></u><br />
I, or my authorized legal representative, hereby give consent to the medical practice to take my photograph at the<br />
time of registration. I understand this photograph will be stored in the medical practice’s ambulatory medical<br />
record electronically as my photo identification.<br /><u><b>11. E-MAIL:</b></u><br />
I hereby consent to provide my e-mail address, so that representatives from the Clinc can e-mail information to<br />
me about health education or disease prevention and up-to-date information about the Clinic, its affiliated<br />
physicians, and our services. I understand I will be able to change my preference at any time. Email Address:&nbsp;</p>
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<td valign="top">Email:</td>
<td>test@email.com</td>
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<p><b><u>12. CELL PHONES:</u></b><br />
I hereby consent to provide my telephone number(s), including my wireless telephone number(s), so that<br />
representatives from the Clinic, its successors or assigns can contact me in any manner including but not limited<br />
to by manually placing a call, by using an automatic telephone dialing system or an artificial or prerecorded<br />
voice, by texting, or by e-mailing, regarding any matter, including but not limited to my medical treatment,<br />
prescriptions, scheduling, billing or collection matters. This consent includes any updated or additional contact<br />
information that I may provide. I understand that I will be able to change my preference at any time.<br /><u><b>13. VIDEOTAPING/RECORDING:</b></u><br />
I understand and agree not to photograph, videotape, audiotape, record or otherwise capture imaging or sound on<br />
any device. I also understand it is my responsibility to assure those accompanying me comply with this requirement.</p>
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<p>The undersigned certifies that s/he has read the foregoing, understands it, accepts its terms, and has received a copy of. I hereby agree to all terms and conditions set forth above and understand that any sections of this consent that I do not consent to, I have struck through and initialed the section that does not have my consent or permission. Any form of electronic signature, such as facsimile or email scan, shall be deemed to be an original signature.</p>
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<td valign="top">Patient's Signature:</td>
<td>test</td>
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<td valign="top">Date:</td>
<td>Wednesday, December 30 2020</td>
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<p></p>
