Welcome and thank you for considering PJG Medical L.L.C. and YourPath (“PJG Medical L.L.C.”, "YourPath", “us”, “Company”) for your medical needs. This document contains important information about our professional services and business policies.
Nurse Practitioner/Licensed Alcohol and Drug Counselor/Outpatient SUD Treatment Services:
The undersigned professionals are a licensed clinical Nurse Practitioner (Philip Gyura) and a licensed 245G treatment facility. The Nurse Practitioner is engaged in private practice providing medical care services to clients directly or via licensed practitioners of the licensed Nurse Practitioner’s Company. The 245G treatment facility is engaged in private practice providing clinical care services via licensed practitioners of the licensed company. In addition, as the owners and managing members, the undersigned Nurse Practitioner and 245G facility provide all medical and clinical services through PJG Medical dba YourPath L.L.C. and YourPath L.L.C. and not personally.
Appointments
Appointments are made by calling (612) 895-1512 during the normal business hours listed at www.yourpathhealth.org. Please call to cancel or reschedule at least 24 hours in advance, or you may be charged for the missed appointment. Third-party payments will not usually cover or reimburse for missed appointments. If you are late, you will be charged for the full amount of the appointment and there will be no pro-rating of the fee. If the Nurse Practitioner has to cancel the appointment, you will be entitled to a refund.
Number of Visits
The number of sessions needed depends on many factors and will be discussed by the care team. Your initial session will involve an evaluation of your needs and depending on your circumstances further evaluative sessions may be required. At the end of the evaluation process the undersigned Nurse Practitioner/Licensed Alcohol and Drug Counselor will be able to provide you with some first impressions of what family practice may include and a treatment plan to follow if both you and Nurse Practitioner/Licensed Alcohol and Drug Counselor agree to work together in medical and clinical care. You should evaluate this information along with your own opinions of whether you feel comfortable working with our team. If you have questions about procedures feel free to discuss them with the Nurse Practitioner and Licensed Alcohol and Drug Counselor at any time. If you have doubts your Nurse Practitioner and Licensed Alcohol and Drug Counselor will be happy to help you set up a meeting with another medical professional for a second opinion.
Confidentiality
Discussions between a Nurse Practitioner/Licensed Alcohol and Drug Counselor and a client are confidential. No information will be released without the client's written consent unless mandated or permitted by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in treatment facilities; sexual exploitation; AIDS/HIV and other communicable disease infection and possible transmission; court orders; criminal prosecutions; child custody cases; suits in which the medical of a party is in issue; situations where the Nurse Practitioner has a duty to disclose, or where, in the Nurse Practitioner/Licensed Alcohol and Drug Counselor's judgment, it is necessary to warn, protect, notify, or disclose; sexual exploitation by a medical professional or member of the clergy; fee disputes between the Nurse Practitioner/Licensed Alcohol and Drug Counselor and the client; a negligence suit brought by the client against the Nurse Practitioner/Licensed Alcohol and Drug Counselor; the filing of a complaint with a licensing board or other state or federal regulatory authority; to regulatory authorities in connection with their compliance or investigatory responsibilities; to employees or agents of the practice for operational purposes; to a supervisor if the Nurse Practitioner is under supervision and for treatment consultations with other medical professional when deemed necessary by the Nurse Practitioner/Licensed Alcohol and Drug Counselor. FOR FURTHER INFORMATION REVIEW THE NOTICE OF PRIVACY PRACTICES FURNISHED TO YOU BY YOUR NURSE PRACTITIONER/LICENSED ALCOHOL AND DRUG COUNSELOR IN CONJUNCTION WITH THIS CLIENT INFORMATION AND CONSENT DOCUMENT.
By signing this information and consent form below you acknowledge receipt of a copy of the Notice of Privacy Practices. If you have any questions regarding confidentiality, you should bring them to the attention of the Nurse Practitioner/Licensed Alcohol and Drug Counselor when you and the Nurse Practitioner/Licensed Alcohol and Drug Counselor discuss this matter further. By signing this information and consent form below, you are giving your consent to the undersigned Nurse Practitioner/Licensed Alcohol and Drug Counselor to share confidential information with all persons mandated or permitted by law, with the agency that referred you, and the managed care company and/or insurance carrier responsible for providing your medical care services and payment for those services, and you are also releasing and holding harmless the undersigned Nurse Practitioner/Licensed Alcohol and Drug Counselor for any departure from your right of confidentiality that may result. Nurse Practitioner/Licensed Alcohol and Drug Counselor avoid conflicts of interest in treating minors or adults involved in custody or visitation actions by not performing evaluations for custody, residence, or visitation of the minor. Nurse Practitioner/Licensed Alcohol and Drug Counselor who treat minors may provide the court or medical professional performing the evaluation with information about the minor from the Nurse Practitioner/Licensed Alcohol and Drug Counselor’s perspective as a treating Nurse Practitioner/Licensed Alcohol and Drug Counselor, so long as the Nurse Practitioner/Licensed Alcohol and Drug Counselor obtains appropriate consents to release information.
Mandated Reporting
Under Minnesota Law, persons in designated professional occupations are mandated to report suspected child abuse or neglect. Persons who work with children and families are in a position to help protect children from harm. These persons are required by law to report to child protection if they know or have a reason to believe that a child is being abused or neglected or that a child has been neglected or abused within the prior three years. As a mandated reporter, the Nurse Practitioner/Licensed Alcohol and Drug Counselor may be required to break confidentiality and report certain information to the appropriate authorities.
Risks of Medical Care
There are no guarantees in Medical Care and the Nurse Practitioner does not make any guarantees with this agreement. You assume the risk of Medical Care by signing this form. The Nurse Practitioner is not liable for any adverse reactions to Medical Care. The Nurse Practitioner may take any reasonable action necessary during Medical Care when there is a dangerous circumstance, as determined by the Nurse Practitioner.
Risks of Clinical Care
There are no guarantees in Clinical Care and the Licensed Alcohol and Drug Counselor does not make any guarantees with this agreement. You assume the risk of Clinical Care by signing this form. The Licensed Alcohol and Drug Counselor is not liable for any adverse reactions to Clinical Care. The Licensed Alcohol and Drug Counselor may take any reasonable action necessary during Clinical Care when there is a dangerous circumstance, as determined by the Licensed Alcohol and Drug Counselor and care team.
After-Hours Emergencies
Please know that neither your Nurse Practitioner and PJG Medical L.L.C. nor YourPath provide twenty-four (24) hour crisis or emergency Medical Care services. Should you experience an emergency necessitating immediate medical attention, immediately call 911 or if you are able to safely transport yourself, go to the nearest hospital emergency room for assistance.
Contacting Your Nurse Practitioner/Licensed Alcohol and Drug Counselor
Your Nurse Practitioner/Licensed Alcohol and Drug Counselor are often not immediately available by telephone. The office number (612) 895-1512 is answered by voice mail that the Nurse Practitioner/Licensed Alcohol and Drug Counselor will monitor from time to time throughout the day. Although the Nurse Practitioner/Licensed Alcohol and Drug Counselor are typically in the office during normal business hours s/he will not take calls when with a client. A reasonable effort will be made to return any call made during normal business hours on the same day it is received, weekends and holidays excepted. Messages left after hours or on weekends or holidays will normally be returned the next business day. If you are difficult to reach, please inform your Nurse Practitioner /Licensed Alcohol and Drug Counselor of times when you will be available.
E-Mail and Text Messages
The undersigned Nurse Practitioner/Licensed Alcohol and Drug Counselor and PJG Medical L.L.C./YourPath may use and respond to e-mail and text messages only to arrange or modify appointments. Please do not send e-mails related to your treatment or Medical Care sessions as electronic communications are not completely secure and confidential. Any Medical or Clinical care-related questions or issues will not be addressed by the Nurse Practitioner/Licensed Alcohol and Drug Counselor in any electronic communication but will be dealt with during your next Medical or Clinical Care session. Any electronic transmissions of information by you are retained in the logs of your service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the service providers. You should know that any e-mails or any communications sent via Facebook, online and specifically the website www.yourpathhealth.org are not secure and you assume the risks of the insecure transmission.
Social Media
Your Nurse Practitioner/Licensed Alcohol and Drug Counselor does not accept friend or contact requests from current or former clients on any social networking sites. Adding clients as friends or contacts on these sites can compromise confidentiality and privacy of both the Nurse Practitioner/Licensed Alcohol and Drug Counselor and the client. It can blur the boundaries of the professional relationship and are not permitted. Any attempt by a client to surreptitiously gain access to the Nurse Practitioner's or Licensed Alcohol and Drug Counselor's personal site(s) will be cause for termination of the Medical Care.
Nurse Practitioner's/Licensed Alcohol and Drug Counselor 's Incapacity or Death
You acknowledge that, in the event the undersigned Nurse Practitioner or Licensed Alcohol and Drug Counselor becomes incapacitated or dies, it will become necessary for another Nurse Practitioner/Licensed Alcohol and Drug Counselor to take possession of your file and records. By signing this information and consent form below, you give consent to allowing another licensed medical professional selected by the undersigned Nurse Practitioner/Licensed Alcohol and Drug Counselor to take possession of your file and records and provide you with copies upon request, or to deliver them to a Nurse Practitioner/Licensed Alcohol and Drug Counselor of your choice. The undersigned Nurse Practitioner/Licensed Alcohol and Drug Counselor will select a successor Nurse Practitioner/Licensed Alcohol and Drug Counselor within a reasonable time and will notify the appointed licensed professional.
Audio and Video Recordings
You acknowledge and, by signing this information and consent form below, agree that neither you nor the undersigned Nurse Practitioner/Licensed Alcohol and Drug Counselor will record any part of your sessions unless you and the Nurse Practitioner/Licensed Alcohol and Drug Counselor mutually agree in writing that the session may be recorded. You further acknowledge that the undersigned Nurse Practitioner/Licensed Alcohol and Drug Counselor objects to you recording any portion of your sessions without the Nurse Practitioner's/Licensed Alcohol and Drug Counselor's written consent. You expressly agree that audio and video recordings used for security or training purposes are not part of Medical or Clinical Care, and are therefore not protected by confidentiality or any other provisions under this agreement.
Distance Medical Care (Telehealth or Telemedicine)
Distance Medical Care includes the practice of medical care delivery, diagnosis, consultation, treatment, transfer of protected health information, and education using synchronous or asynchronous audio, video, or data communications, including email. This is sometimes referred to as “Tele-medicine.”
Identity Verification
You may be expected to provide a copy of your driver's license and other identity verifying documentation requested by the undersigned Nurse Practitioner/Licensed Alcohol and Drug Counselor before any distance Medical Care services are provided.
Payment for Services
For individual Medical Care, the charge for your initial intake and evaluation session is $250 and the charge for any subsequent Medical Care session is $150. These fees are subject to change upon thirty (30) days' prior notice to you. If you are unable to pay, or are not willing to pay, the higher fee after receipt of notice, services may be terminated, and you may be given referrals to other competent providers. YourPath does not normally accept assignment of insurance benefits but may be required to do so in connection with certain managed care contracts. The undersigned Nurse Practitioner will look to you for full payment of your account, and you will be responsible for payment of all charges. Different copayments are required by various group coverage plans. Your copayment is based on the Medical Policy selected by your employer or purchased by you. In addition, the copay may be different for the first visit than for subsequent visits. You are responsible for and shall pay your copay portion of YourPath's charges for services at the time the services are provided. It is recommended that you determine your copayment before your first visit by calling your benefits office or insurance company.
Although it is the goal of YourPath to protect the confidentiality of your records, there may be times when disclosure of your records or testimony will be compelled by law. Confidentiality and exceptions to confidentiality are discussed below. In the event disclosure of your records or the Nurse Practitioner's or Licensed Alcohol and Drug Counselor's/therapist's testimony are requested by you or required by law, regardless of who is responsible for compelling the production or testimony, you will be responsible for and shall pay the costs involved in producing the records and the hourly rate charged by YourPath at the time of the request or service of the subpoena (current rate is $450/hour) for the time involved in traveling to and from the testimony location, reviewing records and preparing to testify, waiting at the location, and giving testimony. Such payments are to be made at the time or prior to the time the services are rendered by any YourPath staff member. The Nurse Practitioner or other YourPath staff may require a deposit for anticipated court appearances and preparation. You will not be entitled to a pro-rated refund.
Privacy and Security of Communications
All electronic communications between you and the undersigned Nurse Practitioner/Licensed Alcohol and Drug Counselor will be transmitted using reasonable measures to ensure confidentiality. You will be responsible to secure and protect the functionality, integrity, and privacy of your hardware, files, and communication. Password protection for accessing your hardware and files is recommended. If others will be accessing the same computer, be aware that programs exist that copy every keystroke you make. It is recommended that you schedule your sessions with the undersigned Nurse Practitioner when and where you can ensure the greatest level of privacy for all communications. Be sure to fully exit all programs and hardware at the end of each session.
Risks Associated With Distance Medical Care
There are privacy and security risks and consequences associated with distance Medical and Clinical Care despite the policies and procedures in place to guard against them. The risks and consequences include, but are not limited to, interrupted or distorted transmission of data or information due to technical failures and access or interception of your protected health information by unauthorized persons.
By signing this information and consent form below, you acknowledge the limitations inherent in ensuring client confidentiality of information transmitted in distance care and agree to waive your privilege of confidentiality with respect to any confidential information that may be accessed by an unauthorized third party despite the reasonable efforts of the undersigned Nurse Practitioner to arrange a secure line of communication.
Distance Medical Care services and care may not be as complete or effective as face-to-face services. The undersigned Nurse Practitioner/Licensed Alcohol and Drug Counselor will continually assess the appropriateness of distance Medical Care for you. If the undersigned Nurse Practitioner/Licensed Alcohol and Drug Counselor determines that you would be better served by receiving different services, such as face-to-face visits, recommendations for treatment and treatment providers or facilities will be provided to you.
Communication Interruptions
If you are unable to connect with the undersigned Nurse Practitioner/Licensed Alcohol and Drug Counselor or are disconnected during a session due to a technological breakdown, please try to reconnect within 5 minutes. If reconnection is not possible the undersigned Nurse Practitioner can be reached at the following phone number: (612) 895-1512.
Consent to Treatment Using Distance Medical Care
I, voluntarily, agree to receive synchronous (or asynchronous) assessment, care, treatment, and services through the use of email and texts and authorize the undersigned Nurse Practitioner to provide such care, treatment, or services as are considered necessary and advisable.
By signing this Agreement, I, the undersigned client, acknowledge that I have read, understood, and agreed to be bound by all the terms, conditions, and information it contains. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.
Legal
This Agreement shall be construed in accordance with, and governed by, the laws of the State of Minnesota as applied to contracts that are executed and performed entirely in Minnesota. The exclusive venue for any court proceeding based on or arising out of this Agreement shall be Hennepin County or Ramsey County, Minnesota. The parties agree to attempt to resolve any dispute, claim or controversy arising out of or relating to this Agreement by arbitration, which shall be conducted under the then current arbitration procedures of the American Arbitration Association any other procedure upon which the parties may agree. The parties further agree that their respective good faith participation in arbitration is a condition precedent to pursuing any other available legal or equitable remedy, including litigation, arbitration or other dispute resolution procedures. If any legal action or any arbitration or other proceeding is brought for the enforcement of this Agreement, or because of an alleged dispute, breach, default or misrepresentation in connection with any of the provisions of this Agreement, the successful or prevailing party or parties shall be entitled to recover reasonable attorneys’ fees and other costs incurred in that action or proceeding, in addition to any other relief to which it or they may be entitled.
Consent to Treatment
I, voluntarily, agree to receive (or agree for my child to receive) Medical assessment, care, treatment, or services, and authorize PJG Medical L.L.C. to provide such care, treatment, or services as are considered necessary and advisable.
I understand and agree that I will participate in the planning of my care (or my child's care), treatment, or services, and that I may stop such care, treatment, or services that I receive (or my child receives) through PJG Medical L.L.C. at any time.
By signing this Client Information and Consent form, I, the undersigned client (or parent/guardian), acknowledge that I have read, understood, and agreed to be bound by all the terms, conditions, and information it contains. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.
Consent to Treatment
I, voluntarily, agree to receive (or agree for my child to receive) Clinical assessment, care, treatment, or services, and authorize YourPath to provide such care, treatment, or services as are considered necessary and advisable.
I understand and agree that I will participate in the planning of my care (or my child's care), treatment, or services, and that I may stop such care, treatment, or services that I receive (or my child receives) through YourPath at any time.
By signing this Client Information and Consent form, I, the undersigned client (or parent/guardian), acknowledge that I have read, understood, and agreed to be bound by all the terms, conditions, and information it contains. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.