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Forms
[/et_pb_text][et_pb_button button_url=”https://form.jotform.com/210726254439153″ url_new_window=”on” button_text=”Patient Registration Form” button_alignment=”center” _builder_version=”4.9.0″ _module_preset=”default” custom_button=”on” button_text_color=”#FFFFFF” button_text_shadow_style=”preset4″ button_text_shadow_horizontal_length=”-0.01em” box_shadow_style=”preset6″ box_shadow_vertical=”-2px” box_shadow_blur=”19px” box_shadow_color=”#000000″][/et_pb_button][et_pb_button button_url=”https://form.jotform.com/210777533177057″ button_text=”Credit Card Authorization” button_alignment=”center” _builder_version=”4.9.0″ _module_preset=”default” background_layout=”dark” box_shadow_style=”preset6″ box_shadow_color=”#000000″][/et_pb_button][et_pb_button button_url=”https://form.jotform.com/210778158799071″ button_text=”Patient Records Request” button_alignment=”center” _builder_version=”4.9.0″ _module_preset=”default” background_layout=”dark” box_shadow_style=”preset6″ box_shadow_color=”#000000″][/et_pb_button][et_pb_button button_url=”/contact-us/” button_text=”Contact Us” _builder_version=”4.9.0″ _module_preset=”77bcb296-b03b-42fe-bbf2-7e95f1b65285″][/et_pb_button][/et_pb_column][/et_pb_row][et_pb_row _builder_version=”4.9.0″ _module_preset=”default”][et_pb_column type=”4_4″ _builder_version=”4.9.0″ _module_preset=”default”][et_pb_text _builder_version=”4.9.2″ _module_preset=”default”]
Our HIPAA Policy
I understand that I have certain rights to privacy regarding my protected health information (PHI). These rights are given under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
I understand that by signing this consent I authorize Belle Meade Addiction Medicine & Psychiatry, PLLC to use and disclose my PHI to carry out treatment (including direct or indirect treatment by other physicians), day-to-day operations of the practice, and medical record-keeping stored on a HIPAA-compliant EMR. Belle Meade Addiction Medicine & Psychiatry, PLLC, and any DBA operating under the PLLC may use vendors who have access to PHI and agree to comply with HIPAA.
Belle Meade Addiction Medicine & Psychiatry, PLLC will only disclose patient information and records upon official written request from the patient and/or authorized patient representative according to local, state, and federal law.
I have been informed of and given the right to review and secure a copy of the Notice of Privacy Practices, which contains a description of uses and disclosures of my PHI and rights under HIPAA.
I understand that Belle Meade Addiction Medicine & Psychiatry, PLLC may change the terms of this notice and will be offered or provided a copy of the updated terms.
If you have any further questions regarding our HIPAA and Privacy Practices, contact us at 713-540-3302.
Our Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED, AND SAFEGUARDED, AND HOW YOU CAN ACCESS THIS INFORMATION.
Belle Meade Addiction Medicine & Psychiatry, PLLC holds your personal health information (PHI) in strict confidence. Belle Meade Addiction Medicine & Psychiatry, PLLC is required by law to maintain the privacy of protected health information of it’s patients. PHI includes records created during the assessment and treatment, such as records of symptoms, examination and test results, diagnoses, treatments, referrals, bills, and payment information.
Under federal or state law as required, Belle Meade Addiction Medicine & Psychiatry, PLLC may use and disclose PHI without authorization for treatment, payment, and healthcare operations. PHI may also be disclosed in cases of abuse, neglect, or domestic violence to a state or federal agency. PHI will only be disclosed with authorized family, friends, or other providers upon the patient or patient representative’s consent.
To exercise any rights described above, submit a request in writing to Belle Meade Addiction Medicine & Psychiatry, PLLC. If you have questions about your rights, call us anytime.
If you believe your privacy rights have been violated, then you may file a written complaint by mailing it or delivering it to our office. You may also submit a complaint to the Secretary of Health and Human Services by writing to:
Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F
HHS Building
Washington, D.C. 20201
“House” Rules and Regulations
“House” rules reference any location that Belle Meade Addiction Medicine & Psychiatry, PLLC is conducting patient care. These rules are to ensure a safe and conducive environment for the provider and the patient.
- Remain respectful and honest with the provider
- Never threaten or show acts of aggression toward the provider
- Never Throw, break, or destroy property
- No drugs or alcohol are allowed unless given according to prescription by the detox specialist and authorized by the physician.
- Comply with any random drug test ordered by the physician
- Must notify the detox specialist if they intend to leave the room or area for any reason.
Failure to comply with the house rules and regulations can result in the patient being expelled from the program, especially if the safety of any provider is violated.
The patient is responsible for any damages (personal or property) sustained by his or her actions.
Scholarships
Belle Meade Addiction Medicine & Psychiatry, PLLC does not offer any scholarships; however, scholarships found and awarded by other organizations or foundations may be accepted.
Drug Testing Policy
For patients enrolling into a 5-day detox, It should be expected that a drug test will be obtained as part of the initial assessment and detox intake. Belle Meade Addiction Medicine & Psychiatry, PLLC reserves the right to drug test a patient at any time during the detox process with or without suspicion. Any subsequent drug testing during the detox is at no cost to the patient.
For patient’s not enrolled in a 5-day detox, a drug test may be requested at any time; however, if the patient refuses to comply with the drug test, Belle Meade Addiction Medicine & Psychiatry, PLLC reserves the right to discontinue the physician-patient relationship.
Grievance Policy
It is the fundamental belief at Belle Meade Addiction Medicine & Psychiatry, PLLC that every patient should be treated equally, fairly, and professionally. In the event the patient believes this fundamental belief is not being met, the patient has the right to enact the grievance policy.
A “patient grievance” is a formal or informal written or verbal complaint that is made to any provider of Belle Meade Addiction Medicine & Psychiatry, PLLC. When possible, the provider should immediately review the situation and attempt to correct it immediately at the time of the complaint. If this is unable to be achieved, the patient should submit a written or verbal grievance to the physician or other appropriate staff member. Billing issues are not considered a part of the grievance policy, as this policy focuses on the quality of care rendered to the patient. Written complaints should always be considered a grievance.
Grievances that cannot be immediately resolved will be reviewed by, at minimum, the physician and other staff as appropriate. the situation should be reviewed for accuracy and an appropriate response formulated to the patient. The patient should be offered a fair and reasonable plan. If the patient does not agree to the grievance resolve, further counteroffers, and considerations may be submitted by either party.
Refunds should be issued according to the refund policy, however, in some extenuating circumstances, the practice may issue or offer an additional refund originally not authorized according to the refund policy if it was determined the practice was deficient in their services to the patient.
If a final resolution cannot be reached by either party, formal patient- providers relations should be terminated. Should the patient believe further grievance is necessary, the patient has the right to pursue legal action or report any gross misconduct by the provider to the local and state governing authority.
Anit-Kickback Policy
Belle Meade Addiction Medicine & Psychiatry, PLLC complies with the federal anti-kickback statute and does not knowingly or willfully offer, pay, solicit, or receive anything of value as an inducement or reward to refer items or services for which payment is available under the federal or state healthcare programs, such as Medicare or Medicaid.
Patient Referral Policy
Belle Meade Addiction Medicine & Psychiatry, PLLC respects patient’s right to privacy. Often, patients may and will benefit from being referred to another resource or medical service for ongoing or more specialized care. In these cases, the Physician will discuss the referral options with the patient to discuss risk, benefit, quality, and other aspects to ensure the best possible referral. Referral options presented to the patient will be based on the historical quality of services review, reputation, and trustworthy programs.
If the patient has any referral options they wish to present will be equally reviewed and considered.
An official referral will only be made once the patient has given written or verbal consent for the Practice to refer the patient. Patient referrals without the knowledge of the patient are strictly forbidden. Belle Meade Addiction Medicine & Psychiatry, PLLC does not refer to any service or practice that provides financial or compensation of any kind in return.
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