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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. 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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>","container_class":"","element_class":"","key":"html_1595377208202","drawerDisabled":false,"wrap_styles_show_advanced_css":0,"label_styles_show_advanced_css":0,"element_styles_show_advanced_css":0,"cellcid":"c3419"},"id":"176"},{"settings":{"objectType":"Field","objectDomain":"fields","editActive":false,"order":2,"label":"HTML","type":"html","default":"<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. 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RESEARCH STUDIES:</u></b><br></p>","container_class":"","element_class":"","key":"html_1595377828019","drawerDisabled":false,"wrap_styles_show_advanced_css":0,"label_styles_show_advanced_css":0,"element_styles_show_advanced_css":0,"cellcid":"c3429"},"id":"180"},{"settings":{"objectType":"Field","objectDomain":"fields","editActive":false,"order":5,"label":"Are you currently a participant in any research study or project?","type":"listselect","key":"are_you_currently_a_participant_in_any_research_study_or_project_1595377903889","label_pos":"default","required":0,"options":[{"errors":[],"max_options":0,"label":"","value":"","calc":"","selected":0,"order":0,"settingModel":{"settings":false,"hide_merge_tags":false,"error":false,"name":"options","type":"option-repeater","label":"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> 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CONSENT TO PHOTO/VIDEO:</b></u>\nI consent to the photographing, videotaping and/or video monitoring, including appropriate portions of my\nbody, for medical and medical record documentation purposes, provided said photographs or videotapes are\nmaintained and released in accordance with protected health information regulations.<br><u><b>10. CONSENT TO PHOTOGRAPH AT THE TIME OF REGISTRATION:</b></u>\nI, or my authorized legal representative, hereby give consent to the medical practice to take my photograph at the\ntime of registration. I understand this photograph will be stored in the medical practice’s ambulatory medical\nrecord electronically as my photo identification.<br><u><b>11. E-MAIL:</b></u>\nI hereby consent to provide my e-mail address, so that representatives from the Clinc can e-mail information to\nme about health education or disease prevention and up-to-date information about the Clinic, its affiliated\nphysicians, and our services. I understand I will be able to change my preference at any time. Email Address:&nbsp;</p>","container_class":"","element_class":"","key":"html_1595378065772","drawerDisabled":false,"wrap_styles_show_advanced_css":0,"label_styles_show_advanced_css":0,"element_styles_show_advanced_css":0,"cellcid":"c3441"},"id":"184"},{"settings":{"objectType":"Field","objectDomain":"fields","editActive":false,"order":9,"label":"Email","type":"email","key":"email_1595378756380","label_pos":"default","required":1,"default":"","placeholder":"","container_class":"","element_class":"","admin_label":"","help_text":"","custom_name_attribute":"email","personally_identifiable":"1","value":"","wrap_styles_show_advanced_css":0,"label_styles_show_advanced_css":0,"element_styles_show_advanced_css":0,"cellcid":"c3444"},"id":"190"},{"settings":{"objectType":"Field","objectDomain":"fields","editActive":false,"order":10,"type":"html","label":"HTML","default":"<p><b><u>12. CELL PHONES:</u></b>\nI hereby consent to provide my telephone number(s), including my wireless telephone number(s), so that\nrepresentatives from the Clinic, its successors or assigns can contact me in any manner including but not limited\nto by manually placing a call, by using an automatic telephone dialing system or an artificial or prerecorded\nvoice, by texting, or by e-mailing, regarding any matter, including but not limited to my medical treatment,\nprescriptions, scheduling, billing or collection matters. This consent includes any updated or additional contact\ninformation 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>\nI understand and agree not to photograph, videotape, audiotape, record or otherwise capture imaging or sound on\nany device. I also understand it is my responsibility to assure those accompanying me comply with this requirement.</p>","container_class":"","element_class":"","key":"html_1595378187270","drawerDisabled":false,"wrap_styles_show_advanced_css":0,"label_styles_show_advanced_css":0,"element_styles_show_advanced_css":0,"cellcid":"c3447"},"id":"186"},{"settings":{"objectType":"Field","objectDomain":"fields","editActive":false,"order":11,"type":"html","label":"HTML","default":"<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. 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