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PROMISE TO PAY:\n</u></b>I understand that I am obligated to pay the account of the ANR Clinic in accordance with the regular rates and\nterms of the Clinic. If I fail to make payment when due and the account becomes delinquent or is turned over to a\ncollection agency or an attorney for collection, I agree to pay all collection agency fees, court costs and attorney’s\nfees. I also agree that any patient or guarantor overpayments on the above Clinic visit may be applied directly to\nany delinquent account for which I or my guarantor is legally responsible at the time of the collection of the\noverpayment.<br><b><u>2. PATIENT CONSENT FOR E-PRESCRIBING (ELECTRONIC PRESCRIBING):</u></b>\nI have been made aware and understand that the medical practices and offices may use an electronic\nprescription system which allows prescriptions and related information to be electronically sent between my\nproviders and my pharmacy. I have been informed and understand that my providers using the electronic\nprescribing system will be able to see information about medications I am already taking, including those\nprescribed 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>\nI understand this Clinic uses an electronic medical record. I understand that the electronic medical record\ncontains information about my health from my past, current and future health care providers. I agree that this\nhealth information may be released through the Clinic’s electronic medical record or by other means (for\nexample, fax, telephone, email, or hand delivery): (1) to the Clinic; (2) to my past, current and future health care\nproviders and other health care organizations that provide care to me; and (3) to any other person named in my\nmedical record who pays for my treatment. These people may use my health information: (1) to treat me; (2) to\nget paid for my treatment, and (3) to do health care operations activities (for example, managing my care,\nproviding quality care, patient safety activities, and other activities necessary to run the Clinic). I understand that\nthese people will have access to all my health information in the medical record, including behavioral health and\nsubstance use disorder information (for example, drug and alcohol treatment), my medical history, diagnosis,\nhospital records, clinic and doctor visit information, medications, allergies, lab test results, radiology reports,\nsexual and reproductive health information, communicable disease- related information (for example, sexually\ntransmitted diseases), and HIV/AIDS-related information. I understand that I may take back this consent at any\ntime, except if my health information has already been released to someone. I also understand that I may\nrequest a list of the health care organizations that have received my substance use disorder information. This\nconsent will expire one year after my death.<br><b><u>4. NOTICE OF PRIVACY PRACTICES:</u></b>\nRequired pursuant to Health Insurance Portability and Accountability Act of 1996 (HIPAA), I acknowledge that I\nhave received a copy of the ANR Clinic’s Notice of Privacy Practices. I hereby consent to the use and\ndisclosure of my protected health information, including information generated through use of virtual health or\ntelemedicine services, as described in the Notice of Privacy Practices. This will include all of my protected health\ninformation generated during hospitalization and outpatient treatment at the Clinic, including but not limited to\ntreatment for mental health, drug and alcohol abuse, communicable diseases such as HIV/AIDS, developmental\ndisabilities, genetic testing, and other types of treatment received.<br><b><u>5. GENERAL CONSENT FOR TESTS, TREATMENT, AND SERVICES:</u></b>\nI have been informed of the treatment procedures considered necessary for me and that the treatments/\nprocedures will be directed by a physician or independent Advanced Practitioner, in accordance with state laws,\nscope of practice, and licensure of medical staff.</p><p><b><u>6. CONSENT FOR VIRTUAL HEALTH/TELEMEDICINE SERVICES:</u></b>\nI hereby consent to engaging in virtual health or telemedicine services, where available, as part of my treatment. I\nunderstand that “virtual health” or “telemedicine services” includes the practice of health care delivery, diagnosis,\nconsultation, treatment, transfers of medical data, and education using interactive audio, video, or data\ncommunications when the health care provider and patient are not in the same physical location.\nThe interactive electronic systems used for these services will incorporate network and software security\nprotocols to protect the confidentiality of patient identification and imaging data and will include measures to\nsafeguard the data to ensure its integrity against intentional or unintentional corruption. I understand that the\npotential benefits of receiving care in this manner include improved access to care and the ability to obtain\nthe expertise of a distant specialist. The potential risks include problems with information transmittal, including\nbut not limited to poor data transfer which may include a poor video and data quality experience, or lack of\naccess to my complete medical record by the remote physician. I understand that all information, including\nimages, will be part of my medical record available to me if requested and with the same restrictions on\ndissemination 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:29:\"wrap_styles_show_advanced_css\";i:0;s:30:\"label_styles_show_advanced_css\";i:0;s:32:\"element_styles_show_advanced_css\";i:0;s:7:\"cellcid\";s:5:\"c3504\";s:18:\"wrap_styles_border\";s:0:\"\";s:17:\"wrap_styles_width\";s:0:\"\";s:18:\"wrap_styles_margin\";s:0:\"\";s:19:\"wrap_styles_padding\";s:0:\"\";s:17:\"wrap_styles_float\";s:0:\"\";s:19:\"label_styles_border\";s:0:\"\";s:18:\"label_styles_width\";s:0:\"\";s:22:\"label_styles_font-size\";s:0:\"\";s:19:\"label_styles_margin\";s:0:\"\";s:20:\"label_styles_padding\";s:0:\"\";s:18:\"label_styles_float\";s:0:\"\";s:21:\"element_styles_border\";s:0:\"\";s:20:\"element_styles_width\";s:0:\"\";s:24:\"element_styles_font-size\";s:0:\"\";s:21:\"element_styles_margin\";s:0:\"\";s:22:\"element_styles_padding\";s:0:\"\";s:20:\"element_styles_float\";s:0:\"\";}s:2:\"id\";s:3:\"176\";}i:1;a:2:{s:8:\"settings\";a:33:{s:10:\"objectType\";s:5:\"Field\";s:12:\"objectDomain\";s:6:\"fields\";s:10:\"editActive\";b:0;s:5:\"order\";i:2;s:11:\"idAttribute\";s:2:\"id\";s:5:\"label\";s:4:\"HTML\";s:4:\"type\";s:4:\"html\";s:7:\"default\";s:404:\"<p><b><u>7. ADVANCE DIRECTIVE ACKNOWLEDGEMENT:\n</u></b>Federal law requires that patients be provided information about their rights to make advance health care\ndecisions, including Living Will, Durable Medical Power of Attorney or designation of surrogate decision made for\nhealth care decisions. If you have already completed any of these documents, please inform your physician and\nthe Clinic.<br></p>\";s:15:\"container_class\";s:0:\"\";s:13:\"element_class\";s:0:\"\";s:3:\"key\";s:18:\"html_1595377354194\";s:14:\"drawerDisabled\";b:0;s:29:\"wrap_styles_show_advanced_css\";i:0;s:30:\"label_styles_show_advanced_css\";i:0;s:32:\"element_styles_show_advanced_css\";i:0;s:7:\"cellcid\";s:5:\"c3508\";s:18:\"wrap_styles_border\";s:0:\"\";s:17:\"wrap_styles_width\";s:0:\"\";s:18:\"wrap_styles_margin\";s:0:\"\";s:19:\"wrap_styles_padding\";s:0:\"\";s:17:\"wrap_styles_float\";s:0:\"\";s:19:\"label_styles_border\";s:0:\"\";s:18:\"label_styles_width\";s:0:\"\";s:22:\"label_styles_font-size\";s:0:\"\";s:19:\"label_styles_margin\";s:0:\"\";s:20:\"label_styles_padding\";s:0:\"\";s:18:\"label_styles_float\";s:0:\"\";s:21:\"element_styles_border\";s:0:\"\";s:20:\"element_styles_width\";s:0:\"\";s:24:\"element_styles_font-size\";s:0:\"\";s:21:\"element_styles_margin\";s:0:\"\";s:22:\"element_styles_padding\";s:0:\"\";s:20:\"element_styles_float\";s:0:\"\";}s:2:\"id\";s:3:\"178\";}i:2;a:2:{s:8:\"settings\";a:64:{s:10:\"objectType\";s:5:\"Field\";s:12:\"objectDomain\";s:6:\"fields\";s:10:\"editActive\";b:0;s:5:\"order\";i:3;s:11:\"idAttribute\";s:2:\"id\";s:5:\"label\";s:17:\"Please Select One\";s:4:\"type\";s:12:\"listcheckbox\";s:3:\"key\";s:31:\"please_select_one_1595472330431\";s:9:\"label_pos\";s:7:\"default\";s:8:\"required\";b:0;s:7:\"options\";a:4:{i:0;a:9:{s:6:\"errors\";a:0:{}s:11:\"max_options\";i:0;s:5:\"label\";s:76:\"I have executed an advance directive and have supplied a copy to the Clinic.\";s:5:\"value\";s:76:\"I have executed an advance directive and have supplied a copy to the Clinic.\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:0;s:12:\"settingModel\";a:10:{s:8:\"settings\";b:0;s:15:\"hide_merge_tags\";b:0;s:5:\"error\";b:0;s:4:\"name\";s:7:\"options\";s:4:\"type\";s:15:\"option-repeater\";s:5:\"label\";s:159:\"Options <a href=\"#\" class=\"nf-add-new\">Add New</a> <a href=\"#\" class=\"extra nf-open-import-tooltip\"><i class=\"fa fa-sign-in\" aria-hidden=\"true\"></i> Import</a>\";s:5:\"width\";s:4:\"full\";s:5:\"group\";s:0:\"\";s:5:\"value\";a:3:{i:0;a:5:{s:5:\"label\";s:3:\"One\";s:5:\"value\";s:3:\"one\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:0;}i:1;a:5:{s:5:\"label\";s:3:\"Two\";s:5:\"value\";s:3:\"two\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:1;}i:2;a:5:{s:5:\"label\";s:5:\"Three\";s:5:\"value\";s:5:\"three\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:2;}}s:7:\"columns\";a:4:{s:5:\"label\";a:2:{s:6:\"header\";s:5:\"Label\";s:7:\"default\";s:0:\"\";}s:5:\"value\";a:2:{s:6:\"header\";s:5:\"Value\";s:7:\"default\";s:0:\"\";}s:4:\"calc\";a:2:{s:6:\"header\";s:10:\"Calc Value\";s:7:\"default\";s:0:\"\";}s:8:\"selected\";a:2:{s:6:\"header\";s:45:\"<span class=\"dashicons dashicons-yes\"></span>\";s:7:\"default\";i:0;}}}s:12:\"manual_value\";b:1;}i:1;a:9:{s:6:\"errors\";a:0:{}s:11:\"max_options\";i:0;s:5:\"label\";s:93:\"I have executed an advance directive and have been requested to supply a copy to the Clinic. \";s:5:\"value\";s:93:\"I have executed an advance directive and have been requested to supply a copy to the Clinic. \";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:1;s:12:\"settingModel\";a:10:{s:8:\"settings\";b:0;s:15:\"hide_merge_tags\";b:0;s:5:\"error\";b:0;s:4:\"name\";s:7:\"options\";s:4:\"type\";s:15:\"option-repeater\";s:5:\"label\";s:159:\"Options <a href=\"#\" class=\"nf-add-new\">Add New</a> <a href=\"#\" class=\"extra nf-open-import-tooltip\"><i class=\"fa fa-sign-in\" aria-hidden=\"true\"></i> Import</a>\";s:5:\"width\";s:4:\"full\";s:5:\"group\";s:0:\"\";s:5:\"value\";a:3:{i:0;a:5:{s:5:\"label\";s:3:\"One\";s:5:\"value\";s:3:\"one\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:0;}i:1;a:5:{s:5:\"label\";s:3:\"Two\";s:5:\"value\";s:3:\"two\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:1;}i:2;a:5:{s:5:\"label\";s:5:\"Three\";s:5:\"value\";s:5:\"three\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:2;}}s:7:\"columns\";a:4:{s:5:\"label\";a:2:{s:6:\"header\";s:5:\"Label\";s:7:\"default\";s:0:\"\";}s:5:\"value\";a:2:{s:6:\"header\";s:5:\"Value\";s:7:\"default\";s:0:\"\";}s:4:\"calc\";a:2:{s:6:\"header\";s:10:\"Calc Value\";s:7:\"default\";s:0:\"\";}s:8:\"selected\";a:2:{s:6:\"header\";s:45:\"<span class=\"dashicons dashicons-yes\"></span>\";s:7:\"default\";i:0;}}}s:12:\"manual_value\";b:1;}i:2;a:9:{s:6:\"errors\";a:0:{}s:11:\"max_options\";i:0;s:5:\"label\";s:111:\"I have not executed an advance directive. I have received information about advance directives from this Clinic\";s:5:\"value\";s:111:\"I have not executed an advance directive. I have received information about advance directives from this Clinic\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:2;s:12:\"settingModel\";a:10:{s:8:\"settings\";b:0;s:15:\"hide_merge_tags\";b:0;s:5:\"error\";b:0;s:4:\"name\";s:7:\"options\";s:4:\"type\";s:15:\"option-repeater\";s:5:\"label\";s:159:\"Options <a href=\"#\" class=\"nf-add-new\">Add New</a> <a href=\"#\" class=\"extra nf-open-import-tooltip\"><i class=\"fa fa-sign-in\" aria-hidden=\"true\"></i> Import</a>\";s:5:\"width\";s:4:\"full\";s:5:\"group\";s:0:\"\";s:5:\"value\";a:3:{i:0;a:5:{s:5:\"label\";s:3:\"One\";s:5:\"value\";s:3:\"one\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:0;}i:1;a:5:{s:5:\"label\";s:3:\"Two\";s:5:\"value\";s:3:\"two\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:1;}i:2;a:5:{s:5:\"label\";s:5:\"Three\";s:5:\"value\";s:5:\"three\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:2;}}s:7:\"columns\";a:4:{s:5:\"label\";a:2:{s:6:\"header\";s:5:\"Label\";s:7:\"default\";s:0:\"\";}s:5:\"value\";a:2:{s:6:\"header\";s:5:\"Value\";s:7:\"default\";s:0:\"\";}s:4:\"calc\";a:2:{s:6:\"header\";s:10:\"Calc Value\";s:7:\"default\";s:0:\"\";}s:8:\"selected\";a:2:{s:6:\"header\";s:45:\"<span class=\"dashicons dashicons-yes\"></span>\";s:7:\"default\";i:0;}}}s:12:\"manual_value\";b:1;}i:3;a:11:{s:6:\"errors\";a:0:{}s:11:\"max_options\";i:0;s:5:\"order\";i:3;s:3:\"new\";b:0;s:7:\"options\";a:0:{}s:5:\"label\";s:126:\"I have not executed any advance directives, and I do not wish to receive information about advance directives from this Clinic\";s:5:\"value\";s:125:\"I have not executed any advance directives and I do not wish to receive information about advance directives from this Clinic\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:12:\"settingModel\";a:10:{s:8:\"settings\";b:0;s:15:\"hide_merge_tags\";b:0;s:5:\"error\";b:0;s:4:\"name\";s:7:\"options\";s:4:\"type\";s:15:\"option-repeater\";s:5:\"label\";s:159:\"Options <a href=\"#\" class=\"nf-add-new\">Add New</a> <a href=\"#\" class=\"extra nf-open-import-tooltip\"><i class=\"fa fa-sign-in\" aria-hidden=\"true\"></i> Import</a>\";s:5:\"width\";s:4:\"full\";s:5:\"group\";s:0:\"\";s:5:\"value\";a:3:{i:0;a:5:{s:5:\"label\";s:3:\"One\";s:5:\"value\";s:3:\"one\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:0;}i:1;a:5:{s:5:\"label\";s:3:\"Two\";s:5:\"value\";s:3:\"two\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:1;}i:2;a:5:{s:5:\"label\";s:5:\"Three\";s:5:\"value\";s:5:\"three\";s:4:\"calc\";s:0:\"\";s:8:\"selected\";i:0;s:5:\"order\";i:2;}}s:7:\"columns\";a:4:{s:5:\"label\";a:2:{s:6:\"header\";s:5:\"Label\";s:7:\"default\";s:0:\"\";}s:5:\"value\";a:2:{s:6:\"header\";s:5:\"Value\";s:7:\"default\";s:0:\"\";}s:4:\"calc\";a:2:{s:6:\"header\";s:10:\"Calc Value\";s:7:\"default\";s:0:\"\";}s:8:\"selected\";a:2:{s:6:\"header\";s:45:\"<span class=\"dashicons dashicons-yes\"></span>\";s:7:\"default\";i:0;}}}s:12:\"manual_value\";b:1;}}s:15:\"container_class\";s:0:\"\";s:13:\"element_class\";s:0:\"\";s:11:\"admin_label\";s:0:\"\";s:9:\"help_text\";s:0:\"\";s:14:\"drawerDisabled\";b:0;s:9:\"min_limit\";s:1:\"0\";s:9:\"max_limit\";s:1:\"1\";s:38:\"listcheckbox_field_limit_error_message\";s:30:\"Please select only one option.\";s:29:\"wrap_styles_show_advanced_css\";i:0;s:30:\"label_styles_show_advanced_css\";i:0;s:32:\"element_styles_show_advanced_css\";i:0;s:38:\"list_item_row_styles_show_advanced_css\";i:0;s:40:\"list_item_label_styles_show_advanced_css\";i:0;s:42:\"list_item_element_styles_show_advanced_css\";i:0;s:7:\"cellcid\";s:5:\"c3511\";s:18:\"wrap_styles_border\";s:0:\"\";s:17:\"wrap_styles_width\";s:0:\"\";s:18:\"wrap_styles_margin\";s:0:\"\";s:19:\"wrap_styles_padding\";s:0:\"\";s:17:\"wrap_styles_float\";s:0:\"\";s:19:\"label_styles_border\";s:0:\"\";s:18:\"label_styles_width\";s:0:\"\";s:22:\"label_styles_font-size\";s:0:\"\";s:19:\"label_styles_margin\";s:0:\"\";s:20:\"label_styles_padding\";s:0:\"\";s:18:\"label_styles_float\";s:0:\"\";s:21:\"element_styles_border\";s:0:\"\";s:20:\"element_styles_width\";s:0:\"\";s:24:\"element_styles_font-size\";s:0:\"\";s:21:\"element_styles_margin\";s:0:\"\";s:22:\"element_styles_padding\";s:0:\"\";s:20:\"element_styles_float\";s:0:\"\";s:27:\"list_item_row_styles_border\";s:0:\"\";s:27:\"list_item_row_styles_height\";s:0:\"\";s:26:\"list_item_row_styles_width\";s:0:\"\";s:30:\"list_item_row_styles_font-size\";s:0:\"\";s:27:\"list_item_row_styles_margin\";s:0:\"\";s:28:\"list_item_row_styles_padding\";s:0:\"\";s:26:\"list_item_row_styles_float\";s:0:\"\";s:29:\"list_item_label_styles_border\";s:0:\"\";s:29:\"list_item_label_styles_height\";s:0:\"\";s:28:\"list_item_label_styles_width\";s:0:\"\";s:32:\"list_item_label_styles_font-size\";s:0:\"\";s:29:\"list_item_label_styles_margin\";s:0:\"\";s:30:\"list_item_label_styles_padding\";s:0:\"\";s:28:\"list_item_label_styles_float\";s:0:\"\";s:31:\"list_item_element_styles_border\";s:0:\"\";s:31:\"list_item_element_styles_height\";s:0:\"\";s:30:\"list_item_element_styles_width\";s:0:\"\";s:34:\"list_item_element_styles_font-size\";s:0:\"\";s:31:\"list_item_element_styles_margin\";s:0:\"\";s:32:\"list_item_element_styles_padding\";s:0:\"\";s:30:\"list_item_element_styles_float\";s:0:\"\";}s:2:\"id\";s:3:\"191\";}i:3;a:2:{s:8:\"settings\";a:33:{s:10:\"objectType\";s:5:\"Field\";s:12:\"objectDomain\";s:6:\"fields\";s:10:\"editActive\";b:0;s:5:\"order\";i:4;s:11:\"idAttribute\";s:2:\"id\";s:4:\"type\";s:4:\"html\";s:5:\"label\";s:4:\"HTML\";s:7:\"default\";s:190:\"<p><b><u>8. RESEARCH STUDIES:</u></b></p><p><b><u></u></b></p><p>Are you currently a participant in any research study or project: (If yes, please briefly describe what is being studied)</p>\";s:15:\"container_class\";s:0:\"\";s:13:\"element_class\";s:0:\"\";s:3:\"key\";s:18:\"html_1595377828019\";s:14:\"drawerDisabled\";b:0;s:29:\"wrap_styles_show_advanced_css\";i:0;s:30:\"label_styles_show_advanced_css\";i:0;s:32:\"element_styles_show_advanced_css\";i:0;s:7:\"cellcid\";s:5:\"c3514\";s:18:\"wrap_styles_border\";s:0:\"\";s:17:\"wrap_styles_width\";s:0:\"\";s:18:\"wrap_styles_margin\";s:0:\"\";s:19:\"wrap_styles_padding\";s:0:\"\";s:17:\"wrap_styles_float\";s:0:\"\";s:19:\"label_styles_border\";s:0:\"\";s:18:\"label_styles_width\";s:0:\"\";s:22:\"label_styles_font-size\";s:0:\"\";s:19:\"label_styles_margin\";s:0:\"\";s:20:\"label_styles_padding\";s:0:\"\";s:18:\"label_styles_float\";s:0:\"\";s:21:\"element_styles_border\";s:0:\"\";s:20:\"element_styles_width\";s:0:\"\";s:24:\"element_styles_font-size\";s:0:\"\";s:21:\"element_styles_margin\";s:0:\"\";s:22:\"element_styles_padding\";s:0:\"\";s:20:\"element_styles_float\";s:0:\"\";}s:2:\"id\";s:3:\"180\";}i:4;a:2:{s:8:\"settings\";a:33:{s:10:\"objectType\";s:5:\"Field\";s:12:\"objectDomain\";s:6:\"fields\";s:10:\"editActive\";b:0;s:5:\"order\";i:7;s:11:\"idAttribute\";s:2:\"id\";s:4:\"type\";s:4:\"html\";s:5:\"label\";s:9:\"HTML Copy\";s:7:\"default\";s:71:\"<p>Who can the Clinic contact with questions about the 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