Registration

Fill out the form and upload Photo ID and Insurance Card (front and back). We will call you to schedule an appointment within 15-30 minutes of receiving your registration form.

I give permission for Restore Health KY, INC and it's Business Partner Wellward Regenerative Medicine to provide me medical and clinical treatment in person or through online communications i.e Telehealth and Telemedicine and all other permissible forms of video communications.

I hereby authorize and give my voluntary consent to the Medical Director and/or any appropriately authorized assistants that he may select to administer or prescribe the drug Buprenorphine or Suboxone, as an element in the treatment for my dependence on narcotics (opiates-based) drugs.,

The procedures necessary to assess and/or treat my condition have been explained to me and I understand it will involve my taking daily doses of Buprenorphine or Suboxone, or other drugs, which will help me control my dependence on Heroin and/or other narcotic drugs.

It has been explained to me Buprenorphine or Suboxone is also a narcotic (opiate-based) drug, which can be harmful if taken without medical supervision. I further understand Buprenorphine or Suboxone is an opiate based (partial agonist) classified as an addictive medication and may, like other drugs used in medical practice, produce adverse results. The alternative methods of treatment, the possible risk involved, and the possibilities of complications have been explained to me, but I still desire to receive Buprenorphine or Suboxone due to the risk of my return to the use of opiates and /or opioids such as Heroin, Oxycontin, Morphine, or other such drugs of the narcotic (opiate) family.

The goal of Buprenorphine or Suboxone treatment is total rehabilitation of the patient. Eventual tapering and withdrawal from the use of all drugs, including Buprenorphine or Suboxone, is an appropriate treatment goal. I realize for some patients Buprenorphine or Suboxone treatment may continue for relatively long periods of time but the periodic consideration shall be given concerning my prospects for tapering and complete withdrawal from Buprenorphine or

I understand I may withdraw from the treatment program and discontinue the use of the drug at any time and I shall be afforded tapering and cessation under medical supervision.

I agree that I shall inform any doctor who may treat me for any medical problem I am enrolled in a narcotic treatment program, since the use of other drugs in conjunction with Buprenorphine or Suboxone may cause me harm.

I also understand during the course of treatment, certain conditions may make it necessary to use additional or different procedures than those explained to me.

I understand these alternate procedures shall be used when the Program Medical Director's judgement is considered advisable.

I certify that no guarantee or assurance has been made as to the results that may be obtained from Buprenorphine or Suboxone treatment. With full knowledge of the potential benefits and possible risks involved.

I consent to Buprenorphine or Suboxone treatment, since I realize I would otherwise continue to be dependent upon and abuse narcotic drugs.

Orientation Checklist and Client Rights

The client rights’ has been provided as part of the client’s orientation. The signatures below indicate that each area has been fully explained and is understood by the consumer. After 1 year of service each client’s will be re-issued client rights’ Information.

Rights and grievance and appeal procedures Services provide, days and hours of operation, expected level of participation 

Access to emergency services, after hours 

Code of Ethics/Conduct Confidentiality policy, limits of confidentiality methods, opportunities, and policy on input 

Explanation of financial obligations, fees, and financial arrangements 

Fire, safety, and emergency precautions 

Policy on restraint 

Policy on tobacco products 

Policy on illicit or licit drugs brought into the program 

Policy on weapons brought into the program Identification of the person responsible for service coordination 

Program rules, including restrictions and the loss and regaining of rights 

AIDS/HIV Prevention Information Hepatitis Prevention & Treatment Information Purpose and process of bio-psychosocial assessment 

Individual plan development Discharge/ transition criteria and procedures

I understand that information regarding my referral for treatment for substance abuse is protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Records 42 CFR Part 2, and cannot be disclosed without any written consent unless otherwise provided for in the regulations. I also understand that expect for action already taken based on my consent, I may revoke this consent at any time. If I do not revoke this consent, it will automatically expire no more than one year from when it is signed or upon my termination from services, whichever comes first

In the event in which the safety of a member of a family that we service is compromised a safety plan is the most effective means of addressing and ensuring that any crisis is rendered nonexistent or minimized. To ensure that you and your family are always safe, we request that you agree to the following terms:

As a volunteer participant in services, I, possession of any weapons or feelings of suicide to the members of the respective clinical team that is working with me and my family. I also agree to not use any item that can inflict injury to me or any member of my family. If the situation arises when my frustration is to the point that I want to physically harm myself or someone else, I will contact a member of the clinical team to process the occurrence in a therapeutic and non-threatening manner.

If the situation is violent in nature or defined as an emergency, I will immediately contact the local authorities by dialing 911 (If applicable I will also contact a family member or family friend, , at as an additional resource to assist. I, or members from the clinical team that is working with me and my family, may also contact my caseworker, probation officer, or the referral source to inform them of any violent/suicidal occurrences or threats/expressions of violence/suicidal occurrences. Upon informing the clinical team members of possible violent/suicidal thoughts, and it is deemed that I present to be a danger to myself or others, I understand that they have the ethical and clinical obligation to contact the proper authorities.

The contents of a counseling, intake, or assessment session are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. It is the policy of this organization not to release any information about a client without a signed release of information. Noted exceptions are as follows:

Duty to Warn and Protect

When a client discloses intentions or a plan to harm another person, the health care professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client. In addition, it may be necessary for the health care professional to take steps for the client to be placed in a restricted hospital environment to ensure the safety of the client and of others.

Abuse of Children and Vulnerable Adults

If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse or neglect, the health care professional is required to report this information to the appropriate social service and/or legal authorities.</p>

Prenatal Exposure to Controlled Substances

Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

In the Event of a Client’s Death

In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child’s or spouse’s records.

Professional Misconduct

Other health care professionals must report professional misconduct by a health care professional. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.

Court Orders

Health care professionals are required to release records of clients when a court order has been placed. Clients who are on probation, court ordered to treatment or referred by the Department of Juvenile Justice, Department of Human Resources or the county Juvenile Court may have waived certain rights to confidentiality when entering the treatment program.

Audio/Video Taping

In the event it becomes necessary to audio and/or video tape a client for treatment or supervision purposes, a specific consent form for the purpose of audio and/or video will be required. No recordings of any kind will be conducted without the expressed consent of the client.

Other Provisions

Restore Health KY, INC does not conduct research on any of their clients. Outcome measures, as it pertains to the effectiveness or non-effectiveness of the treatment services are collected and analyzed to ensure that the best quality treatment is provided. No personal information on any client is disclosed, nor can any client be identified by any of outcome information collected.

Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes type of services, dates/times of services, diagnosis, treatment plan, and description of impairment, progress of therapy, case notes, and summaries.

Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed. Clinical information about the client is discussed. In some cases notes and reports are dictated/typed within the clinic or by outside sources specializing (and held accountable) for such procedures. When couples, groups, or families are receiving services, separate files are kept for individuals for information disclosed that is of a confidential nature. The information includes (a) testing results, (b) information given to the mental health professional not in the presence of other person(s) utilizing services, (c) information received from other sources about the client, (d) diagnosis, (e) treatment plan, (f) individual reports/summaries, and (h) information that has been requested to be separate. The material disclosed in conjoint family or couples sessions, in which each party discloses such information in each other’s presence, is kept in each file in the form of case notes. In the event in which the company or mental health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality.

Show consideration and respect towards staff, other consumers and the property of others.

To provide accurate information of past and present complaints, past illnesses and hospitalizations, medications, and any perceived risks in your care and unexpected changes in your condition.

To meet financial obligations agreed to with Restore Health KY, INC and its programs.

To participate in developing your individualized resiliency/recovery/treatment or service plan.

To take medications as prescribed.

To support the program by participating to the best of your ability and by being on time for all scheduled appointments and activities.

To comply with the rules of the service location.

To respect the confidentiality, privacy, and property of others who are receiving services with you.

To report changes in your condition to those responsible for your care and welfare.

To be fully informed of all services available to them. The charges for those services are available to client as well as the right to examine and review bills for treatment, regardless of payment source. 

To receive a written notice of the address and telephone number of the state licensing authority in order to obtain responsibilities of licensing the program and investigating consumer complaints which appear to violate rules.

To obtain a copy of the program and most recent completed report of licensing inspection from the program upon written request

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY PRIVACY PRACTICES

To access or inspect your health care information unless a physician determines that the record review would be detrimental to your well being. 

To obtain a copy of your health care information for as long as the information is retained. (A reasonable fee may be charged for copying

To request in writing that Restore Health KY, INC and its programs restrict the use and disclosure of your confidential health care information.

To receive a copy of the notice of the Restore Health KY, INC HIPAA privacy practices.

To make a reasonable request in writing to receive phone, written or e-mail communications from Restore Health KY, INC . and its programs by alternative means or locations.

To request a list of when and to whom your health care information was released without your authorization within 6 years of your request for non-routine disclosures made on or after April 14, 2003. 30. 

To request an amendment to your health care information

Your rights as a client, including confidentiality of your participation in evaluation and treatment services, will be observed in accordance with O.C.G.A. 37-3-166, 37-4-125, 37-7-166, DHR Rules and Regulations for Consumer Rights, Chapter 290-0-9; 42 U.S.C. 290dd-2,and Restore Health KY, INC . 

Consumer Rights and Responsibilities Policy #2330, Restore Health KY, INC . program policies and any other applicable laws, regulations, and policies, including the federal Health Insurance Portability and Accountability Act (HIPAA) privacy regulations. 

A summary of these rules and regulations will be reviewed with you and are available for inspection at each service location. You also will be provided a copy of the CompServ Health . HIPAA Privacy Notice. 

This information will be reviewed on an annual basis with you.

YOU HAVE THE RIGHT:

To services without discrimination on account of race, religion, sex, ethnicity, age, sexual orientation, disability or cultural background.

To exercise all fundamental human, civil, constitutional, and statutory rights to which you are entitled as a legally competent citizen unless such rights are limited under due process of law.

To be treated in a manner that respects your individual dignity and protects your health and safety at all times.

To receive care that is suited to your needs in the least restrictive environment available that affords reasonable protection from harm, exploitation, and coercion.

To receive prompt and confidential services in a respectful and dignified manner even if you are unable to pay, subject to a review of your financial status.

To refuse services, after being informed of the potential risks and consequences of refusal, unless a physician or licensed psychologist determines that refusal would be unsafe for you or others, or a court mandates the service.

To receive care and treatment suited to your needs in a skillful, safe and humane manner with full respect for your dignity and personal integrity.

To a written individualized service plan.

To participate in planning individualized service plan and to be promptly and fully informed of any changes in the plan of treatment.

To participate, to the extent possible, in your own care and treatment, to be told your diagnosis and to participate in the development and implementation of plan of care.

To be informed of the benefits, side effects and risks of psychotropic medications in a manner and language that you can understand.

To be given the opportunity to secure legal counsel at your expense.

To receive considerate and respectful care and to be free from physical, verbal, sexual, chemical, and mental abuse, neglect, humiliation or mistreatment. Emergency interventions may only be applied when necessary to protect the consumers from injury to himself/herself or others according to the procedures outlined by the organization.

To be free from time-out procedures unless such procedures are used solely for the purpose of providing effective treatment to you and protecting your safety and that of others.

To be free from isolation, physical and chemical restraints unless such interventions are required to protect you or others from injury, or such restraints are otherwise determined to be required for your treatment.

To have and retain personal property which does not jeopardize the safety of the consumer or other consumers or staff and have such property treated with respect.

To converse privately, have convenient and reasonable access to telephone, mail, and to see visitors.

Parents/guardians of children or adolescents have the right to be involved on behalf of their children with limited exceptions.

To file a complaint without fear of restraint, interference, coercion, discrimination or retaliation. Any Restore Health KY, INC . (and its programs) staff person or the Client and Family Advocate can take your complaint and/or assist you in completing the Client & Family Grievance form.

All client’s have the right to expect that their records are confidential unless you have given permission to give out information or reporting is required or permitted by law. When the organization releases records to others, such as insurance, it emphasizes the records are confidential.

PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI” This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHIS that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

How we may use and disclose information about you:

For Treatment.

Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

For Payment.

We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations.

We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

I agree to notify Restore Health KY, INC . when there is a change in my insurance coverage or county of residence immediately

I hereby authorize payment directly to Restore Health KY, INC of any insurance or government program otherwise payable to me for services rendered. If my visit today is with a clinician that is Non by my insurance company, I understand that I will be responsible for those charges. Any refunds shall be applied to any other outstanding balance for which I am responsible at Restore Health KY, INC. 

Assignment of Benefits 

I hereby authorize payment directly to Restore Health KY, INC of any insurance or government program benefits otherwise payable to me for services rendered. If my visit today is with a clinician that is Non Covered by my insurance company, I understand that I will be responsible for those charges. Any refunds due me shall be applied to any other outstanding balance for which I am responsible at Restore Health KY, INC

I hereby acknowledge that Restore Health KY utilizes online social media platform and will be creating an account using my name and or email address for a username. I will not invite anyone that is not approved Restore Health KY patients and or staff.