Explanation of Medication-Assisted Treatment

This explanation of Medication-Assisted Treatment is intended to provide a general framework for addiction treatment. Ultimately, all medical decisions pertaining to a patient’s course of addiction treatment will be at the Ideal Option, PLLC practitioner’s sole discretion and, by signing below, you acknowledge and agree that your course of addiction treatment may vary from the explanation below.

Intake: You will be given a comprehensive substance dependence assessment, as well as an evaluation of mental status and physical exam. The pros and cons of the treatment medications recommended will be presented to you. Treatment expectations, as well as issues involved with maintenance and medically supervised tapering off the medication will be discussed.

Induction: Treatment begins here. You will be switched from your current substance of misuse (alcohol, heroin, methadone, prescription painkillers, etc.) to your treatment medication. Your provider will explain the induction process to you.

If you are prescribed buprenorphine for opioid use disorder, you must be in a state of moderate withdrawal for the medication to work well. If you are not in moderate withdrawal, the medication might make you feel worse rather than better (intensifying withdrawal symptom). This is called precipitated withdrawal.

It is really important to be truthful with your practitioner about the last time you used, how much you took, which other drugs or medications you used and when you last used them, and how much you took. Your practitioner needs this information to determine the timing of your dose of treatment medication.

When you leave the office, the practitioner will likely give you a prescription that will last until your next appointment.

Since an individual’s tolerance and reactions to the medicine vary, daily appointments may be scheduled, and medications will be adjusted until you no longer experience withdrawal symptoms or cravings.

Stabilization & Maintenance: This is the second phase of treatment. During this phase, your practitioner may continue to adjust your dose of medication until you find the dose that works for you. It is important to take your medicine as directed. During this phase is when you may also begin working on your treatment goals. At times when you feel stressed, or experience triggers or cravings, your practitioner may suggest a dose adjustment, or there may be a need to change the frequency of visits.

As you achieve your treatment goals and feel confident in your progress, your practitioner may suggest a dose decrease. The maintenance phase is different for every patient. It may last a few weeks for some patients and a few years for others. The most important parts of this phase are your functionality and safety. Some examples of good functionality are active employment, active school, lack of legal trouble, caring for your family, stable finances and just a general improvement in your overall life circumstances.

Tapering off: There are no time limits for treatment. Length of therapy is determined by you and your practitioner. If you and your practitioner agree that the time is right for a medical taper, he or she will slowly lower your dose (known as a taper), taking care to minimize withdrawal symptoms. If you feel at risk for relapse during a taper, let your practitioner know. You can be re-stabilized and continue maintenance if needed.

Please note: The treatment medicine prescribed may be a narcotic medication indicated for the maintenance treatment of substance use disorder, available only by prescription and must be taken as prescribed. It is illegal to sell or give away your medicine.

If at any time you have questions or concerns about your treatment, please call 877-522-1275. We have a dedicated line that will connect you to a nurse 24 hours a day.

Copyright © 2021 Ideal Option PLLC. All Rights Reserved.

Revised 03/31/2021

I freely and voluntarily agree to comply with the following terms of this contract for treatment of my substance use disorder and I understand that my compliance with this contract is expected for my continued receipt of treatment from Ideal Option:

1. I agree that I will keep my medication in a safe and secure place away from children.
2. I will take the medication as my Ideal Option practitioner prescribes. If a change in medication is necessary, I will contact my Ideal Option practitioner first and will not alter the way I take my medication without first consulting my Ideal Option practitioner.
3. I will keep and be on time to all my appointments and be respectful and courteous to the office staff and other patients.
4. I will keep my Ideal Option practitioner informed of all my medications (including herbs and vitamins) and medical problems during my treatment.
5. I understand that I should not get prescription opioid medications from any other practitioner outside of Ideal Option, unless my Ideal Option practitioner is aware and agrees it is medically appropriate.
6. I understand and agree that my prescriptions will be filled at local pharmacies and not at long-distance pharmacies, except as otherwise determined by my practitioner at his/her discretion.
7. If I am going to have a medical procedure that will cause pain, I will let my practitioner know in advance so that my pain will be adequately treated.
8. I understand that I may be prescribed medications at my scheduled appointments and that I typically will not be prescribed medications prior to any scheduled appointments.
9. If I miss an appointment, lose my medication, or my medication gets stolen, I understand that prescription will not be refilled.
10. I will not arrive at the office intoxicated or under the influence of drugs. If I come to the office intoxicated, I understand that the practitioner may not see me, and I may not be prescribed more medication until the next scheduled office visit.
11. I understand that it is illegal to share, give away or sell my medication. I understand that such mishandling of my medicationis a serious violation of this contract and my treatment will be terminated permanently without any recourse for appeal.
12. Violence, threatening language or behavior, or participating in any illegal or disruptive activity at the office will result in treatment termination without any recourse for appeal and possible legal charges filed.
13. I understand that random urine drug testing is a treatment requirement. I understand that if I’m unable to provide a urine sample, it is at the providers discretion to order and perform oral swab testing.
14. I understand that if I refuse this test, it may affect treatment and medication prescriptions.
15. I understand that I may be called at random times to bring my medication bottle(s) into the office for a pill count and I agree to do so when requested. I understand that failure to do so and/or missing medication doses could result in treatment termination, if determined appropriate by my Ideal Option practitioner, at his/her sole discretion.
16. I understand that my treatment may require providing observed urine samples. If I do not provide a requested observed urine sample, it will count as a positive drug test and may affect my treatment and medication prescriptions.
17. I understand that frequent visits are essential to ensure my safety while in treatment. I agree to comply with the frequency determined by my practitioner.
18. I understand that people have died by mixing the type of medications prescribed by Ideal Option with other drugs like alcohol and benzodiazepines (Valium, Klonopim, Xanax, etc.) and mixing prescribed medications with other medications or other drugs of abuse can be dangerous.
19. I understand that due to the high-risk nature of combining alcohol and medications prescribed by Ideal Option that I may be asked to perform a breathalyzer test. If I do not provide a breathalyzer test, it will count as a positive test and may affect my treatment and prescriptions.
20. I agree to follow my Ideal Option practitioner’s recommendation for additional counseling, patient education and relapse prevention programs and/or help with other problems, to assist me in my treatment.
21. I understand that there is no fixed length of time for being in treatment.
22. I understand that I am expected to stop all social use of any mind/mood-altering substances while in this program.
23. I understand that there are alternatives to medication-assisted treatment including, but not limited to the following, and my Ideal Option practitioner will discuss these with me and provide a referral at my request: medical withdrawal and drug free treatment; Naltrexone Treatment; and Methadone Treatment.
24. I understand that if I am pregnant or plan to become pregnant, I will notify my provider to discuss potential side effects of prescribed medications, and to coordinate care with my OB.

Copyright © 2021 Ideal Option PLLC. All Rights Reserved.

Revised 03/31/2021

I authorize Ideal Option, PLLC to communicate with and disclose to one another the following information to any Third-Party Payor (Commercial Insurance Company/Medicaid/Medicare/etc.) related to my care at Ideal Option, PLLC for the purpose of Billing and Collection.

Complete Patient Record for Billing and Collection, including progress reports, chart notes, urine drug testing results, lab tests, treatment plan, demographics, and verification of funding source(s), and billing documentation.

I authorize Ideal Option, PLLC to disclose to any third-party payor all necessary information and relevant portions of my patient record for the purpose of receiving payment for services rendered.

I authorize Ideal Option, PLLC to disclose to any third-party payor all necessary identifying demographic information for the purpose of protecting against an existing threat to life or of serious bodily injury, including circumstances which constitute suspected child abuse and neglect and verbal threats against third parties.

I understand that my alcohol/drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has already been taken in reliance on it (including the provision of treatment services in reliance on a valid consent to disclose information to a third-party payer), and that in any event this consent expires 365 days after my deactivation from Ideal Option as a patient.

I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes. I acknowledge that the information to be released was fully explained to me and that this consent is given of my own free will and that by signing I have reviewed and understand the terms of this consent. I have been provided a copy of this document.

Copyright © 2021 Ideal Option PLLC. All Rights Reserved.

Revised 03/31/2021

 

• Ideal Option is in-network with most insurances.
• Patients are responsible for paying deductibles, co-pays and co-insurance (see below).
• If you do not have insurance, you will be required to make payments at every visit. The total amount due may differ depending on what laboratory services are needed to provide you with the safest and most effective treatment.

By signing beloe, you confirm the following:

• I understand that the cost of medication and other treatment(s) are not included in this policy—only services provided by Ideal Option are included in this.
• I understand the conditions of this Payment Agreement and agree that my account must remain current.
• I understand that failure to pay fees on time will violate this Payment Agreement.
• I understand that a violation of this Payment Agreement may result in termination from the program and all services discontinued.

Please contact an Ideal Option Financial Counselor at (877) 522-1275 to discuss self-pay or out of network appointment type costs and laboratory service costs.

 

Definitions

Co-payments, Co-insurance, and deductibles. Most insurance plans have cost sharing elements, in which the patients are required to pay portions of their care. If a patient does not pay these amounts, the insurance will not pay for these services. Co-payments, co-insurance and deductibles must be paid at the time of service.

Proof of insurance. All patients must complete our patient information form before seeing the provider. We must obtain a copy of your driver’s license and you must provide proof of valid insurance.

Claims submission. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Claims denied due to the insurance company requesting information from you may be your responsibility.

Coverage changes. If your insurance changes, it is your responsibility to notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

Copyright © 2021 Ideal Option PLLC. All Rights Reserved.

Revised 03/31/2021

The undersigned hereby appoints and designates Ideal Option as my duly authorized representative and assigns my rights and medical benefits/insurance reimbursement as described below. This assignment is effective during any legal or administrative process relating to any claim submitted by Ideal Option on my behalf, which shall include, but is not limited to claim submissions, appeals, Independent Review Organization requests and any legal process relating to a claim submitted on my behalf for health insurance benefits; and/or any request for disclosure of documents and/or materials relating to a claim submitted on my behalf.

I hereby assign my right to assert any and all causes of action for judicial review to Ideal Option. I intend for my personal standing under ERISA's disclosure and civil enforcement procedures under 29 U.S.C. §§ 1024 and 1132 to be hereby transferred to my assignee, so that it may seek judicial review of denied claims and/or disclosure under 29 U.S.C. § 1132(a)(1)(B), 29 U.S.C. § 1132(a)(3), and/or 29 C.F.R. 2560.503-1. This assignment specifically includes an assignment of my rights to seek relief as a claimant under 29 U.S.C. § 1132(c) and my rights to seek attorney fees under 29 U.S.C. § 1132(g). The assignment of benefits and ERISA rights by me is complete: I retain no interest in the benefits and/or rights due to me under these claims for medical care and/or facility fees.

I have read and fully understand this agreement. Should this assignment be prohibited in part or in whole under any anti-assignment provision of my policy/plan, please advise and disclose to Ideal Option in writing such anti-assignment provision within 30 days upon receipt of my assignment, otherwise this assignment should be reasonably expected to be effective and such anti-assignment is waived. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

Copyright © 2021 Ideal Option PLLC. All Rights Reserved.

Revised 03/31/2021

What is Telemedicine?

Telemedicine refers to treatment services that are delivered through electronic communications between a health care provider and a patient or other person who is involved in the patient’s care. The parties use specialized equipment, such as video cameras and monitors, to interact in real time. Some communications, such as transmission of patient records between health care providers, may not occur in real time. 

What are the Expected Benefits?

The expected benefits of telemedicine include, but may not be limited to:

• Improved access to medical care by enabling a patient to receive health care services remotely;
• More efficient medical evaluation and management; and
• Obtaining expertise of a distant health care provider or specialist. 

What are the Possible Risks?

As with the delivery of any medical service, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

• Information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the health care provider;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment or communication network; and
• In very rare cases, security protocols could fail, causing a breach of privacy of personal information.

By signing this form, I understand the following:

• I understand that the laws that protect the privacy and confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed except as permitted by law;
• I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time.  If I choose to withdraw this consent, Ideal Option will attempt to accommodate.  However, this may result in less flexibility in scheduling appointments.  
• I understand that telemedicine may involve electronic communication of my personal health information to other health care providers who may be located in other areas, including out of state; and
• I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured. 

Copyright © 2021 Ideal Option PLLC. All Rights Reserved.

Revised 03/31/2021

By signing below, you certify that you have read and understand this Patient Informed Consent for Laboratory Services in its entirety, and herby consent to providing specimens of your urine, blood, or other bodily fluids to Ideal Option for laboratory testing, as appropriate, for the diagnosis and treatment of Substance Use Disorder (SUD) and other conditions as identified by your Ideal Option Provider.

Urine Drug Testing (UDT)

Ideal Option uses urine drug testing to evaluate, assess, and manage a patient’s condition. UDT can improve your provider’s ability to screen for and detect substance use, including prescription drug misuse, abuse, and diversion; diagnose and treat substance use disorders; manage chronic care for substance use disorders to support and sustain recovery; and direct therapy with prescription drugs.

You are required to provide samples of your urine for drug testing, including random testing, to receive treatment at Ideal Option. 

As a consequence, you have the option to refuse testing, however your prescribing provider can refuse to provide care and prescribe and/or initiate or continue medications. 

If your test results are negative for a prescribed medication or positive for non-prescribed medications or illegal substances, it is considered an aberrant result and Ideal Option may adjust your treatment plan, including safe discontinuation of your medication, terminate your treatment, or refer you to another treatment provider. Any refusal or inability to provide a urine sample will be treated as an aberrant result. Inability to provide a urine will be reviewed by your prescribing provider who will consider the basis of your inability and act accordingly. 

Other Laboratory Testing

Early detection and treatment are generally associated with better outcomes. Many conditions can be detected and treated by your prescribing provider and the tests we recommend are useful to help improve your health and to ensure that you are free of conditions commonly observed among individuals with a history of substance use disorder.  It is well documented that individuals with substance use disorders are at an increased risk for certain medical conditions, including hepatitis, human immunodeficiency virus (HIV), sexually transmitted infections (STI), hormone imbalances, liver disease, and kidney disease because of illicit substances, prescribed medications that have been taken in ways other than directed. 

Medications ordered by your personal provider or your prescribing provider at Ideal Option may have an effect on a fetus or unborn child. It is important to know what measures you are taking to prevent pregnancy and if you are pregnant.  To better manage these risks, have knowledge of your health status, and appropriately guide your care, your Ideal Option provider may order certain laboratory tests. These tests may include, but are not limited to, the following:  Tests for infectious diseases, such as hepatitis A, hepatitis B, hepatitis C, sexually transmitted infections, and HIV; Complete blood counts; Electrolyte panels; Liver function tests; Kidney function tests; Hormone levels, and Pregnancy tests.

You may opt out (i.e., refuse to give your consent) of any of the “other laboratory testing” described in this section. If your provider determines that the results of “other laboratory testing” is essential to manage your care and you have opted out of testing, you may be required to provide answers to questions or results of tests that would have been ordered.  If your provider cannot safely prescribe to you without results, you may have safe discontinuation of your medications, termination of your treatment, or refer you to another treatment provider.  If you want to opt out of certain laboratory tests, please list them here please tell the front desk. You may revoke this consent at any time by notifying Ideal Option in writing.

Copyright © 2021 Ideal Option PLLC. All Rights Reserved.

Revised 03/31/2021

THIS NOTICE DESCRIBES HOW MEDICAL, DRUG, AND ALCOHOL RELATED INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

 This Notice is being provided to you as a requirement of two federal laws: The Health Insurance Portability and Accountability Act (HIPAA) 42 U.S.C. §1320d et seq., 45 C.F.R. Parts 160 & 164, and the Confidentiality of Alcohol and Drug Abuse Patient Records, 42 U.S.C. § 290dd-2, 42 CFR Part 2 (“Part 2”).

Under these laws, Ideal Option, PLLC (“Ideal Option”) may not say to a person outside Ideal Option that you are a patient in the clinic, nor may Ideal Option disclose any information identifying you as an alcohol or drug abuser or disclose any other Protected Health Information (“PHI”) except as permitted by federal law. Your PHI means any written and oral health information about you, including demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.

Ideal Option must obtain your written consent before it can disclosure information about you for payment purposes. For example, Ideal Option must obtain your written consent before it can disclose information to your health insurer in order to be paid for services. Generally, you must also sign a written consent before Ideal Option can share information for treatment purposes or for health care operations. However, federal law permits Ideal Option to disclosure information without your written permission: Pursuant to an agreement with a qualified service organization/business associate; For research, audit or evaluations; To report a crime committed on Ideal Option premises or against Ideal Option personnel; To medical personnel in a medical emergency; To appropriate authorities to report suspected child abuse or neglect; As allowed by a court order.

For example, Ideal Option can disclosure information without your consent to obtain legal or financial services, or to another medical facility to provide health care for you, as long as there is a qualified service organization/business associate agreement in place. Before Ideal Option can use or disclosure any information about your health in a manner which is not described above, it must first obtain your specific written consent allowing it to make the disclosure. Any such written consent may be revoked by you in writing or verbally.

Your Rights: Under HIPAA you have the right to request restrictions on certain uses and disclosures of your health information. Ideal Option is not required to agree to any restrictions you request, but if it does agree then it is bound by that agreement and may not use or disclosure any information which you have restricted except as necessary in a medical emergency. You have the right to request that we communicate with you by alternative means or at an alternative location. Ideal Option will accommodate such requests that are reasonable and will not request an explanation from you. Under HIPAA, you also have the right to inspect and copy your own health information maintained by Ideal Option, except to the extent that the information contains psychotherapy notes or information complied for use in a civil or administrative proceeding or other limited circumstances.

Ideal Option Duties: Ideal Option is required by law to abide by the terms of this notice. Ideal Option reserves the right to change the terms of this notice and to make new notice provisions effective for all PHI it maintains.

Contact Person: Ideal Option’s contact person for all issues regarding patient privacy and your rights under the federal privacy standards is the Privacy Officer. Information regarding matters covered by this Notice can be requested by contacting the Privacy Officer. If you feel that your privacy rights have been violated by Ideal Option, you may submit a complaint to Hannah Phenneger Ideal Option’s Privacy Officer by calling 877-522-1275

Effective Date: This Notice is effective June 6, 2019

PLEASE SEE WWW.IDEALOPTION.COM  FOR THE FULL NOTICE OF PRIVACY PRACTICES

Copyright © 2021 Ideal Option PLLC. All Rights Reserved.

Revised 03/31/2021

Introduction:

Ideal Option is evaluating the effectiveness of medication-assisted treatment and emergency room utilization by patients receiving medication-assisted treatment. Ideal Option participates in an electronic health information exchange with other health care providers to track patient visits to an emergency room in order to better serve the needs of its patients. The exchange is known as “EDIE” (Emergency Department Information Exchange). EDIE records a patient’s health information when a patient visits an emergency room. This information is maintained in an electronic health information exchange database which complies with the privacy regulations of the Health Insurance Portability and Accountability Act (HIPAA).

The purpose of this Consent is to obtain your permission for Ideal Option to receive information from EDIE about your visits to an emergency room. Ideal Option will need to submit demographic information (“Information”) about you to EDIE to determine if you have been to the emergency room. This Information includes: Name; Date of Birth; Social Security Number; Address; and Phone number.

By submitting this Information to the EDIE, Ideal Option DOES NOT inform any other health care providers that you are a patient or have been seen by Ideal Option.

Also, Ideal Option will also use the data from EDIE to evaluate how often our patients are being seen in an emergency room once in treatment with Ideal Option. Ideal Option will also evaluate trends and track the impact of medication-assisted treatment on frequency of emergency department visits. Ideal Option may publish these trends while maintaining the privacy of its patients’ data.

Why is Ideal Option collecting this data?

The data that is gathered from EDIE system will be used to better inform your care. Ideal Option will also use the data to evaluate how often our patients are being seen in an emergency room once in treatment with Ideal Option, and to evaluate trends and track the impact medication-assisted treatment has with regard to frequency of emergency department visits. It is our hope that such information will enable Ideal Option to better serve the needs of our patients.

What will happen if I give my consent?

Ideal Option will submit your information to EDIE and Ideal Option may share certain limited data with others in order to further advance the field of medication-assisted treatment. Ideal Option may publish de-identified data consistent with the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164.

Who can I contact if I have any questions?

You may contact Ashley Brighton at (877)-522-1275 with any questions or concerns about this consent or your participation.

Copyright © 2021 Ideal Option PLLC. All Rights Reserved.

Revised 03/31/2021

During the course of your practitioner/patient relationship with all practitioners at Ideal Option, PLLC (“Ideal Option”), these practitioners will order certain laboratory tests for purposes related to your medical care and treatment. In connection with any laboratory services performed by Ideal Option laboratories, you are hereby advised that both Dr. Jeffrey Allgaier and Dr. Kenneth Egli, (physicians employed by Ideal Option), have an ownership or beneficial interest in Ideal Option and its testing laboratories, and that the laboratories are owned by Ideal Option PLLC. 

This information is being provided to help you make an informed decision about your health care. You have the right to choose your laboratory. You have the option of obtaining the laboratory services ordered by your practitioner at a different laboratory other than Ideal Option laboratories. You will not be treated differently by your practitioner or any practitioner at Ideal Option Clinic if you choose to use a different laboratory.

If you have any questions concerning this form, please contact Ideal Option Clinic at (877) 522-1275. 

Your signature below evidences your receipt of this Practitioner Disclosure Form and that you have been informed of your ability to have your laboratory services performed by a different laboratory. Further, you acknowledge by signing below that you have read and signed this Practitioner Disclosure Form prior to having your laboratory services performed at Ideal Option laboratories. By signing below, you acknowledge that your laboratory services will be performed at Ideal Option laboratories, but that you always have the ability to choose a different laboratory if and when you choose, upon providing written notice to Ideal Option of such choice to use a different laboratory and the name and contact information of that laboratory.

To assist you in making an informed decision on where to obtain laboratory services, please contact a patient care representative at (877) 222-1275 for alternate laboratories near you.

Copyright © 2021 Ideal Option PLLC. All Rights Reserved.

Revised 03/31/2021

It is the policy of Ideal Option that all prescriptions be sent electronically within 24 hours of your scheduled appointment. Please DO NOT go to the pharmacy or call staff to inquire about where your prescription is unless you have reached 24 hours after your scheduled appointment.

Our staff and providers are working diligently to ensure all prescriptions are sent over within the 24-hour allotted time.

Please note, there may be times when your prescription requires a prior authorization. The authorization must be submitted and approved by your insurance for the medication to be covered in part or in full. Ideal Option has a designated Authorization Department that assists in facilitating the authorization process. Please be aware, that some insurances can take up to 2 business days to approve an authorization and although your prescription will be sent within 24 hours, it may not be covered by your insurance until the prior authorization is approved. Ideal Option works diligently to facilitate and expedite the authorization process.

Should you have any questions or concerns regarding your prescription authorization, please call 1-877-522-1275. 

By signing below, you authorize Ideal Option, PLLC to send prescription information (name, date of birth, medication, dosage, duration, etc.) to employees of the pharmacy specified through the Kiosk or otherwise communicated to Ideal Option. 

Additionally, you agree not to use any pharmacy other than the ones selected through the Kiosk for the duration of your treatment, unless specific arrangements have been made with Ideal Option. 

You understand that you may withdraw this consent at any time, either verbally or in writing, except to the extent that action has been taken in reliance on it. This consent will last while you are being treated by Ideal Option, unless you withdraw your consent during treatment.

This consent will expire 365 days after you complete your treatment, unless Ideal Option is otherwise notified by you. You understand that the information to be released may contain information pertaining to substance use disorder treatment and/or other illnesses. You understand that these records are protected by the Code of Federal Regulations Title 42 Part 2 (42 CFR Part 2), which prohibits the recipient of these records from making any further disclosures to third parties, without the express written consent of the patient.

Copyright © 2021 Ideal Option PLLC. All Rights Reserved.

Revised 03/31/2021

The purpose of this consent is to inform and obtain your written consent to record both audio and video during visits with your practitioner at Ideal Option.

The recording obtained is strictly for education and training purposes and will not be disclosed outside of Ideal Option without your written consent or if otherwise permitted by federal regulations.

Your participation is voluntary, and you should immediately raise any concerns or areas of discomfort during your visit with your practitioner. You have the right to request that your visit not be recorded and to withdraw your previous consent at any time.

Please be aware that Substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and again cannot be disclosed without your written consent unless otherwise permitted by the regulations.

By signing below, you relinquish any rights to the recording and understand the recording may be copied and used internally for training and educational purposes only by Ideal Option without further permission.

Copyright © 2021 Ideal Option PLLC. All Rights Reserved.

Revised 03/31/2021

Ideal Option offers a variety of text message services to our patients including, but not limited to, upcoming appointment reminder messages, messages offering re-enrollment services, medication alert messages, missed appointment follow-up reminders, and feedback collection messages.

Test message charges may apply depending on your text message service plan.

Ideal Option additionally offers email services to our patients including, but not limited to, appointment reminders, medical record requests, documentation requests, and feedback collection requests. Emails that contain any identifying patient health information will be sent in a secure format.

Ideal Option cannot be held responsible for messages or content sent to a mobile telephone number or email address you have supplied, or no longer use, or if someone has access to your phone or email account and can view your messages.

By signing below, you acknowledge that you have read the above information and give consent to be included in this text messaging and email service and for Ideal Option to send text messages and emails to your mobile phone number and email address listed on file.

You may stop this service any time by texting STOP to any text message or by calling Ideal Option at 877.522.1275.

Copyright © 2021 Ideal Option PLLC. All Rights Reserved.

Revised 03/31/2021