Crossroads Recovery Center, LLC. Lori Eaton, PMHNP.

CROSSROADS RECOVERY CENTER
Consent for Treatment

I authorize Crossroads Recovery Center to perform all clinical services deemed necessary in the evaluation of program/client appropriateness.
I have been advised and understand that Crossroads Recovery Center adheres to all Federal laws of confidentiality and any suspected violations of the law must be reported.
I give my consent for the duration of my treatment and 90 days after discharge for Crossroads Recovery Center to release information regarding my progress and location in treatment to Referring Agencies, Probation and Officers of the Court for the purpose of assuring my compliance with an order for treatment (if requested).
I agree to submit urine/take alcohol test, if requested, for drug testing.
I understand that failure to do so could result in negative termination. Urine/alcohol results may be utilized as treatment interventions or may be completed as determined by external requirements.
I understand that I am responsible for all fees for the duration of my program.
I understand that if I fail to follow any communicable-disease-related referrals, Crossroads Recovery Center will need to report such to the County Health Department.  In case of severe medical emergency, I have listed an emergency medical contact on a release form and do authorize Crossroad Recovery Center to contact that party should such an emergency occur.
Print Name_________________________________ Date: _____________________
Signature __________________________________

The following information is needed to process your insurance claims.  It is your responsibility to provide complete and accurate information so that claims can be submitted in a timely manner. Please print clearly and complete all inquiries on both pages.

CLIENT INFORMATION:

First Name _______________ Middle Initial___ Last Name __________________

Address ___________________________________________________________

     City ____________________ State __________ Zip Code _____________

Home Phone ____________________ Social Security # ______-_____-_______

Work Phone ____________________   Birth Date ______/______/__________

Fax ___________ Mobile Phone ______________ Sex   ☐  Male         ☐    Female

Email ______________________ Other Phone ____________________________

Patient Status: ☐ Single  ☐ Married  ☐ Other   Referring Physician _______________

                             ☐ Employed    ☐ Full-Time Student    ☐ Part-Time Student

Is Patient’s Condition Related to                     Hospitalization Dates:
            ☐ Employment?                                   From ____/___/___ To ____/___/____
            ☐ Auto Accident?  State ________
            ☐ Other Accident?

RESPONSIBLE PARTY:           Check here if Responsible Party is same as Client ☐

First Name ________________ Middle Initial___ Last Name _________________

Address ___________________________________________________________

     City ______________________ State ____________ Zip Code ____________

Home Phone _____________________ Social Security # _____-_____-_______

Work Phone ______________________   Birth Date ______/_____/_________

Fax ____________ Mobile Phone _______________ Sex   ☐  Male       ☐    Female

Email ____________________________ Other Phone ______________________

PRIMARY INSURANCE COMPANY:

☐ Medicaid    ☐ Group    ☐ HMO    ☐ PPO    Other _______________________

Insured’s I.D. Number __________________ Social Security # _____-____-______

Insurance Company __________________________________________________

            Claims Address ________________________________________________

            City _______________________ State ___________ Zip Code _________

            Phone Number ___________________ Contact Person ________________

Insured’s Name (Last, First, Middle) ______________________________________

Client Relationship to Insured    ☐ Self    ☐ Spouse    ☐ Child    ☐ Other

Insured’s Address _____________________________________________________

     City ________________________ State ____________ Zip Code ___________

     Telephone: Home _______________ Work  ______________ FAX ____________

     Mobile __________________ Email ____________________________________

Insured’s Policy Group FECA Number ______________________________________

Date of Birth ______/______/__________  Sex  ☐ Male   ☐ Female

Employer’s or School’s Name _____________________________________________

Insurance Plan Name ___________________ Is there another health plan? ☐ Yes  ☐ No

 If “Yes” please complete the following information about the other health plan:

SECONDARY INSURANCE COMPANY:

☐ Medicaid    ☐ Group    ☐ HMO    ☐ PPO    Other _________________________

Insured’s I.D. Number ____________________ Social Security # ____-____-_______

Insurance Company ____________________________________________________

            Claims Address __________________________________________________

            City _________________________ State __________ Zip Code __________

            Phone Number ________________ Contact Person _____________________

Insured’s Name (Last, First, Middle) ________________________________________

Client Relationship to Insured    ☐ Self    ☐ Spouse    ☐ Child    ☐ Other

 ___________________________________               _________________________
Client’s Signature                                                       Date
(Parent/Guardian if client is a minor)

___________________________________               _________________________
Responsible Party’s Signature                                    Date
___________________________________               _________________________
Insured’s Signature                                                     Date

Rev 2023

FINANCIAL POLICY          CROSSROADS RECOVERY CENTER, LLC

 Below are the terms of agreement regarding payment for sessions at Crossroads Recovery Center, LLC:

1.     Session fees are based on a clinical hour, which insurance can define at 45-60 minutes direct with the counselor or professional.
2.     If I, the patient, fail to appear for an appointment without a 24-hour notice of cancellation, prevailing appointment fees will be charged, and I will be responsible for payment.
3.     I understand that if I am late to a session, that session will end at the time originally scheduled. It is my responsibility to arrive on time.
4.     Services including phone calls, emails, record reviews, and professional consults at times other than the scheduled therapy session are the patient’s responsibility. These services will be billed per quarter of an hour.
5.     I authorize my health insurance to provide payment of benefits to Crossroads Recovery Center, LLC.
6.     I understand records of my treatment may be shared with my insurance company when necessary to process claims.
7.     I understand I am responsible for payment if my insurance company declines payment.

I have reviewed this document and understand the contingencies stated above.

__________________________________________________
Printed Name
__________________________________________________       ______________
Signature                                                                                            Date

ADULT PATIENT

STIMULANT MEDICATION AGREEMENT

Patient Name:________________________________________________________
(Print Full Name)
Address:_____________________________________________________________
(Print Street, City, State, Zip Code)

 I understand that I have been prescribed a stimulant medication for treatment of attention deficit/hyperactivity disorder (ADD/ADHD). I understand the goals of treatment are to improve my ability to function. I understand that evidence of improved functioning is a requirement of continued treatment. I acknowledge that these medications are controlled substances and are tightly regulated by state and federal law because of a high risk for abuse.

This Agreement is valid from _____/_____/_____ until _____/_____/_____.

I UNDERSTAND THAT ANY VIOLATION OF THIS AGREEMENT MAY POSE A HEALTH RISK TO MYSELF AND OTHERS. I UNDERSTAND THAT BY SIGNING THIS AGREEMENT, I MUST ABIDE BY THE AGREEMENT RULES AND THAT FAILURE TO ABIDE BY THESE RULES WILL RESULT IN THE TERMINATION OF STIMULANT MEDICATION PRESCRIPTION PRIVLIGES AND POSSIBLY THE TERMINATION OF SERVICES FROM MY CROSSROAD RECOVERY CENTER PROVIDER.

Medication Name, Dose & Frequency: ___________________________________
Pharmacy Name: ____________________________________________________
Pharmacy Address/Telephone Number: ___________________________________

Agreement Rules

1.    I agree I will take the medication as prescribed by ______________ only according to the agreed upon schedule.

2.    I agree not to increase the dose of medication on my own and I understand that doing so may lead to terminating this agreement.

3.    I agree I will not seek, accept from others, or use medication for ADD/ADHD other than those prescribed by my Provider. This includes medications or drugs I might get from any other Providers, medications I might borrow or accept from family or friends, my use of any illicit or street drugs (including marijuana).

4.    I agree to communicate fully and on a timely basis with my Provider about the intensity of my symptoms, their effects on my daily life, the effectiveness of the medication in relieving my symptoms, and any significant side effects that occur.

5.    I agree to fill my prescriptions only at the pharmacy listed above. If I change pharmacies, I agree to contact my Provider’s office and provide them with the name, address, and telephone number of the new pharmacy. I agree that under no circumstances will I obtain medications from more than one pharmacy at a time.

6.    I agree new prescriptions will be provided as written prescriptions only and only at scheduled appointments.

7.    I agree to notify my Provider if I become pregnant.

8.    I agree that if I do not keep my appointment, I will not receive a new prescription. Appointment cancellations or no-show appointments may be grounds for immediate termination of this Agreement.

9.    I agree I will not abuse alcohol. If my Provider advises, I agree I will not use any alcohol.

10. I agree to cooperate with random drug testing and/or “pill counts” at any time even between scheduled appointments. I understand that if my drug test result does not reflect that I am taking my medications as prescribed or if my pill counts are inaccurate or if I refuse to cooperate in any way, the medication may be stopped, and this Agreement terminated.

11. I agree to accept it is my responsibility to protect and secure my medications. This includes keeping the medication out of the reach of children.

12. I agree to accept generic brands of my medications if available.

13. I understand that my Provider and my pharmacy will cooperate fully with any city, state, or federal law enforcement or regulatory agency in the event of any possible misuse, sale, or other diversion of my medication or alteration of my prescription.

14. I understand that lost or stolen medications will be refilled only under special circumstances. A copy of a police report will be required for any stolen stimulant medication prescriptions before replacements will be considered. I understand that the presentation of multiple police reports over a short period of time indicates that I am not properly safeguarding my medications and may result in termination of this Agreement.

15. I understand that my Provider is under no obligation to provide these medications to me, and that s/he reserves the right to discontinue these medications at any time.

16. I understand that my Provider may require specialist evaluation of my treatment. I agree to keep appointments when my Provider refers me for specialty care. I understand that my Provider will send a report of my care and a copy of this Agreement when a referral is made.

17. I understand that I may be required to show valid photo identification when picking up prescriptions for these stimulant medications. The only forms of acceptable photo identification are a driver's license, an identification card issued by the New Hampshire Department of Motor Vehicles, a military ID, or a passport.

18. I understand that it is a Felony Criminal Offense and a violation of this Agreement to obtain stimulant medications by fraudulent means or to possess stimulant medications without a legitimate prescription.

19. I understand that it is a Felony Criminal Offense and a violation of this Agreement to alter prescriptions for stimulant medications.

20. I understand that it is a Felony Criminal Offense and a violation of this Agreement to give or sell stimulant medications to others.

I understand that this Agreement may also be terminated for any of the following reasons:

1.    If I seek to obtain any medication from a source other than my Provider.

2.    If I give, sell or in any way distribute prescribed medications to any other person(s).

3.    If I conduct any illegal drug activities.

4.    If I am abusive, violent, or otherwise threatening towards any patients or visitors.

5.    If I do not tell the truth about whether or not I have taken my medications.

6.    If I attempt to forge or alter a prescription.

7.    If my medical condition declines to a point at which, in the judgement of my Provider, continued therapy with this medication presents a danger to my well-being or safety.

8.    If there is evidence that I am no longer receiving a reasonable therapeutic benefit from the medication, or my Provider determines I am no longer a good candidate to continue the medication.

I authorize my Provider to share this information with pharmacists, other Providers, local medical facilities, or the New Hampshire Board of Pharmacy as s/he deems necessary.

I understand that any change in my medication prescriptions will require a new written agreement.

Patient/Guardian Signature: __________________________     Date: _____________

Print Name: ___________________________________________________________

CROSSROADS RECOVERY CENTER, LLC                  LORI EATON PMHNP-BC

Contract for Controlled Substance Prescriptions 

Controlled substance medications (i.e., benzodiazepines, Suboxone, and stimulants) are very useful, but have potential for misuse; therefore, they are controlled by local, state, and federal government. They are intended to improve function and/or ability to work, not simply to feel good. Because my provider is prescribing such medications for me to help manage my condition, I agree to the following conditions:

1.    I am responsible for my controlled substance medications. If the prescription of medication is lost, misplaced, or stolen, or if I use it up sooner than prescribed, I understand that it will not be replaced.  (PATIENT INITIAL _____)

2.    I will not request or accept controlled substance medication from any other physician or individual while I am receiving such medication from Lori Eaton PMHNP. Besides being illegal to do so, it may endanger my health. The only exception is if it is prescribed while I am admitted to a hospital.  (PATIENT INITIAL ______)

3.    Refills of controlled substance medication:

a.   Will not be made if I “run out early,” I am responsible for taking the medication in the dose prescribed and for keeping track of the amount remaining.

b.   Will not be made as an “emergency,” such as a Thursday afternoon because I suddenly realize that I will run out tomorrow and the office will be closed. I will call at least seventy-two (72) hours in advance if I need assistance wit a controlled medication prescription.

c.   Lost or stolen prescriptions for controlled medications will be filled prior to the next due date. PLEASE NOTE: NO EXCEPTIONS WILL BE MADE.

4.    I understand the importance of following my treatment plan as directed by Lori Eaton, PMHNP and agree:

a.   To keep my appointments (including follow-ups and any referrals). While being prescribed controlled substances, I agree to meet twice a month for therapy and skill building.

b.  To permit urine drug screening without prior notice.  (PATIENT INITIAL __________)

5.    I understand that if I violate any of the above conditions, my controlled substance prescription and/or treatment by Lori Eaton, PMHNP, may be terminated immediately. If the violation involves obtaining controlled substances from another individual, as described above, I may also be reported to other healthcare providers, medical facilities, pharmacies, and other authorities.   (PATIENT INITIAL __________)

6.    I understand that the main treatment goal is to improve my ability to function and/or work. In consideration of that goal and the fact that I am being given potent medication to help me reach that goal, I agree to help myself by the following better health habits: Non-use of “street” drugs” I understand that using “street drugs” will impact my progress and counteract with any prescribed medications. They are not only mind altering, but also illegal. Continued use after warning can be cause for your care to be terminated immediately from Crossroads Recovery Center and may be reported to the authorities.   (PATIENT INITIAL __________)

I have read this contract and fully understand its content. In addition, I fully understand the consequences of violating this contract.

Patient Signature: ______________________________ Date: ________________

Witness Signature: _____________________________ Date: ________________

CROSSROAD RECOVERY CENTER

USES AND DISCLOSURE OF HEALTH INFORMATION

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY

This notice is effective as of April 15, 2003.

USES AND DISCLOSURE OF HEALTH INFORMATION

Crossroads Recovery Center is committed to protecting the privacy of the personal and health information we collect or create as part of providing health care services to our clients, known as “Protected Health Information” or “PHI”. PHI typically includes your name, address, date of birth, billing arrangements, care, and other information that relates to your health, health care provided to you, or payment for health care provided to you.

This notice of Health Information Privacy Practices (the Notice) describes Crossroads Recovery Center’s duties with respect to the privacy of PHI, Crossroads Recovery Center’s use of and disclosure of PHI, client rights and contact information for comments, questions, and complaints.

 CROSSROADS RECOVERY CENTER’S PRIVACY PROCEDURES
AND LEGAL OBLIGATIONS

Crossroads Recovery Center obtains most of its PHI directly from you, through care applications, assessments, and direct questions. We may collect additional personal information depending upon the nature of your needs and consent to make additional referrals and inquiries. We may also obtain PHI from community health care agencies, other government agencies, or health care providers as we set up your service arrangements.

Crossroads Recovery Center is required by law to provide you with this notice and to abide by the terms of the Notice currently in effect.  Crossroads Recovery Center reserves the right to amend this notice at any time to reflect changes in our privacy practices. Any such changes will be applicable to and effective for all PHI that we maintain, including PHI we created or received prior to the effective date of the revised notice. Any revised notice will be mailed to you or provided upon request.

Crossroads Recovery Center is required by law to maintain the privacy of PHI. Crossroads Recovery Center will comply with federal law and will comply with any state law that further limits or restricts the uses and disclosures discussed below. In order to comply with these state and federal laws, Crossroads Recovery Center has adopted policies and procedures that require its employees to obtain, maintain, and use and disclose PHI in a manner that protects client privacy.

USES AND DISCLOSURES WITH YOUR AUTHORIZATION

Except as outlined below, Crossroads Recovery Center will not use or disclose your PHI without your written authorization. The authorization form is available from Crossroads Recovery Center (at the address and phone number below). You have the right to revoke your authorization at any time, except to the extent that Crossroads Recovery Center has taken action in reliance on the authorization.

The law permits Crossroads Recovery Center to use and disclose your PHI for the following reasons without your authorization:

For Your Treatment: We may use or disclose your PHI to physicians, psychologists, nurses and other authorized healthcare professionals who need your PHI in order to conduct an examination, prescribe medication or otherwise provide health care services to you.

To Obtain Payment: We may use or disclose your PHI to insurance companies, government agencies or health plans to assist us in getting paid for our services. For example, we may release information such as dates of treatment to an insurance company in order to obtain payment.

For our Health Care Operations: We may use or disclose your PHI in the course of activities necessary to support our health care operations such as performing quality checks on your employee services. We may also disclose PHI to other persons not in Crossroads Recovery Center’s workforce or to companies who help us perform our health services (referred to as “Business Associates”) we require these business associates to appropriately protect the privacy of your information.

As Permitted or Required By The Law: In some cases we are required by law to disclose PHI. Such as disclosers may be required by statute, regulation court order, government agency, we reasonably believe an individual to be a victim of abuse, neglect or domestic violence for judicial and administrative proceedings and enforcement purposes.

For Public Health Activities: We may disclose your PHI for public health purposes such as reporting communicable disease results to public health departments as required by law or when required for law enforcement purposes.

For Health Oversight Activities: We may disclose your PHI in connection with governmental oversight, such as for licensure, auditing and for administration of government benefits.

To Avert Serious Threat to Health and Safety: We may disclose PHI if we believe in good faith that doing so will prevent or lessen a serious or imminent threat to the health and safety of a person or the public.

Disclosures of Health-Related Benefits or Services: Sometimes we may want to contact you regarding service reminders, health related products or services that may be of interest to you, such as health care providers or settings of care or to tell you about other health related products or services offered at Crossroads Recovery Center. You have the right not to accept such information.

Incidental Uses and Disclosures: Incidental uses and disclosures of PHI are those that cannot be reasonably prevented, are limited in nature and that occur as a by-product of a permitted use or disclosure. Such incidental uses and disclosures are permitted as long as Crossroads Recovery Center use reasonable safeguards and use or disclose only the minimum amount of PHI necessary.

To Personal Representatives: We may disclose PHI to a person designated by you to act on your behalf and make decisions about your care in accordance with state law. We will act according to your written instructions in your chart and our ability to verify the identity of anyone claiming to be your personal representative.

To Family and Friends: We may disclose PHI to persons that you indicate are involved in your care or the payment of care. These disclosures may occur when you are not present, as long as you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest. We may also disclose limited PHI to public or private entity that is authorized to assist in disaster relief efforts in order for that entity to locate a family member or other person that may be involved in caring for you. You have the right to limit or stop these disclosures.

 YOUR RIGHTS CONCERNING PRIVACY

 Access to Certain Records: You have the right to inspect and copy your PHI in a designated record set except where State law may prohibit client access. A designated record set contains medical and billing and case management information. If we do not have your PHI record set but know who does, we will inform you how to get it. If our PHI is a copy of information maintained by another health care provider, we may direct you to request the PHI from them. If Crossroads Recovery Center produces copies for you, we may charge you up to $1.00 per page, up to a maximum of fee of $50.00. Should we deny your request for access to information contained in your designated record set, you have the right to ask for the denial to be reviewed by another healthcare professional designated by Crossroads Recovery Center.

Amendments to Certain Records: You have the right to request certain amendments to your PHI if, for example, you believe a mistake has been made or a vital piece of information is missing. Crossroads Recovery Center is not required to make the requested amendments and will inform you in writing of our response to your request.

Accounting of Disclosures: You have the right to receive an accounting of disclosures of your PHI that were made by Crossroads Recovery Center for a period of six (6) years prior to the date of your written request. This accounting does not include for purposes of treatment, payment, health care operations or certain other excluded purposes, but includes other types of disclosures, including disclosures for public health purposes or in response to a subpoena or court order.

Restrictions: You have the right to request that we agree to restrictions on certain uses and disclosures of you PHI, but we are not required to agree to your request. You cannot place limits on uses and disclosures that we are legally required or allowed to make.

Revoke Authorizations: You have the right to revoke any authorizations you have provided, except to the extent that Crossroads Recovery Center has already relied upon the prior authorization.

Delivery by Alternate Means or Alternate Address: You have the right to request that we send you PHI by alternate means or to an alternate address.

Complaints & How to Contact Us: If you believe your privacy rights have been violated, you have the right to file a complaint by contacting Crossroads Recovery Center at the address and/or phone number indicated below. You also have the right to file a complaint with the Secretary of the United States Department of Health and Human Services in Washington, D.C.  Crossroads Recovery Center will not retaliate against you for filing a complaint.

If you believe your privacy rights have been violated, you may make a complaint by contacting Barry Pietrantonio, HIPAA Privacy Officer at 603-912-4490 or the Secretary for the Department of Health and Human Services. No individual will be retaliated against for filing a complaint.

The U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Washington, D.C. 20201

Toll Free: 1-877-696-6775

Please be aware that mail sent to the Washington, D.C. area offices takes an additional   3-4 days to process due to changes in mail handling resulting from the Anthrax crisis of October 2001.