NEW PATIENT INTAKE FORM

To ensure that we provide you with the best care possible, please complete our electronic new patient intake form below prior to your initial mental health assessment and appointment.
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INTAKE FORM

    • DEMOGRAPHIC INFORMATION

      EMERGENCY CONTACT

      INSURANCE INFORMATION

      MENTAL HEALTH DATA

    • PATIENT CONFIDENTIALITY AGREEMENT

      KAV Health Group provides treatment which includes confidential clinical and medical services. KAV Health Group is legally bound by State and Federal regulations for both mental health and substance abuse services. Once an appointment is made, no information can be disclosed to anyone without your written permission on a Release of Information 42 C.F.R Part 2 Form.

      What this means for you:

      KAV Health Group will not share your information with a third-party without your written consent. KAV Health Group staff will work diligently to protect information provided in counseling sessions. However, there are certain limitations to confidentiality. Please note the following exceptions to confidentiality:

      • Confidentiality does not apply to cases of reported or suspected abuse/neglect of children or the elderly.
      • Confidentiality does not apply to cases of potential harm to self or others.
      • In cases of medical emergency, information may be shared with medical personnel.
      • On rare occasions, there will be a request by a court for your records. KAV Health Group may be required to share that information. KAV Health Group will make an effort to discuss with you any instances where your confidentiality may be breached. KAV Health Group will make an effort to share only information which is deemed legally necessary.
      • Information must be shared with your insurance provider, should you choose to use insurance. This information may be seen by various employees of the insurance provider. There is also a potential that certain members of your employer may see this information.

      Your Responsibility:

      It is also your responsibility to protect the confidentiality of other patients. Do not discuss other patients (names, diagnoses, etc.) outside of group therapy sessions. In order to protect your confidentiality, all patients must agree to honor this policy as well. If you are found to have breached this confidentiality policy, you may be discharged from the program.

      By signing this form, you acknowledge that there may be instances where KAV Health Group must share your confidential information and you recognize that you are responsible for helping maintain the confidentiality of other patients. Discussing other patients outside of the group sessions may result in your termination from the program.

      PATIENT AGREEMENT

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    • MEDICATION ADHERENCE AT KAV HEALTH GROUP

      Medication adherence simply means taking the medication as prescribed/ordered for you by a health care professional - whether taken in pill form, inhaled, injected, or applied topically. Not taking medication as prescribed is called non-adherence. Many people never fill their medications or they may never pick up their filled prescriptions from the pharmacy. Other people bring their medication home but don't follow their health care professional's instructions - they skip doses or stop taking the medicine. Specifically, non-adherence includes:

      • Not filling a new medication or not refilling an existing medication when you are supposed to
      • Stopping a medicine before the instructions say you should
      • Taking more or less of the prescribed/ordered medicine; or taking the medication at the wrong time of day

      All medicines have risks and benefits. When a patient works with their health care professional to decide to use medicine to help manage a long-term health condition, he or she accepts certain risks in exchange for potential health benefits. Patients can help manage those risks by using medicines safely, including storing & disposing of them safely.

      Importance of Medication Adherence Specifically at KAV Health Group

      Some of the medications prescribed at KAV Health Group are controlled substances which have an increased requirement for compliance from patients. This is very important because of the health and possible legal consequences of such controlled substances.

      • All patients must take their medication EXACTLY as prescribed/ordered.
        • Do not attempt to adjust the dose of your medication up or down without the consultation of your provider/physician.
      • Keep medications in a safe and secure location.
        • Theft of medication will not result in an early refill.
      • If you have any questions concerning your medication, set up an appointment with your provider/physician.
      • Because of the medication you are taking combined with a history of substance abuse, it is vital that you coordinate your other medical appointments or surgical/dental procedures that you have with KAV Health Group. Plan ahead.
      • It is important that you tell your primary care physician or any other physician who writes prescriptions for you that you are receiving treatment services at KAV Health Group.
      • DO NOT EVER SELL YOUR MEDICATION OR TRY TO BUY MEDICATION FROM SOMEONE. THIS WILL LIKELY RESULT IN IMMEDIATE DISMISSAL FROM THE PROGRAM AND CAN RESULT IN LEGAL CONSEQUENCES FOR YOU AS A PATIENT.
      • NON-ADHERENCE WITH YOUR MEDICATION REGIMEN CAN ALSO RESULT IN RESTRICTIONS BY YOUR INSURANCE COMPANY THAT CANNOT BE RESOLVED BY THE TEAM AT KAV Health Group. YOU MAY LOSE THE ABILITY TO GET YOUR MEDICATIONS PAID FOR BY INSURANCE.
    • CONSENT FOR DRUG AND ALCOHOL TESTING

      It is the policy of KAV Health Group to perform alcohol & drug screens on all patients via urinalysis. Patients will be screened at intake as well as periodically and randomly throughout treatment. A positive alcohol and/or drug screen is not cause for immediate termination from the program.

      However, a positive alcohol and/or drug screen could result in a change in a patient’s treatment plan. In some cases urine specimens may be sent to outside laboratories for screening. If a specimen is sent to an outside laboratory and results in a positive screening, the positive result will be reviewed by KAV Health Group staff with the patient. Alcohol and/or drug screens may not be covered by an insurance provider. If this is the case, the patient will be responsible for payment for the alcohol and/or drug screen. Refusal to consent to an alcohol or drug screen will be recorded as a “positive” result in the patient record. Repeated positive alcohol and/or drug screens can result in a change in treatment plan and/or termination from the program.

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    • CONSENT TO RECEIVE TREATMENT VIA TELEHEALTH

      Telemedicine is the remote diagnosis and treatment of patients by means of telecommunications technology. Providers may include practitioners, specialists, subspecialists, and counselors. The information may be used for diagnosis, treatment, follow-up and/or education. It may include any of the following:

      • Patient medical records
      • Live two-way audio and video
      • Output data from medical devices and sound and video files Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and medical data and will include measures to safeguard data to ensure its integrity against intentional or unintentional corruption.

      Expected Benefits:

      • Improved access to medical care by enabling a patient to remain in a clinical setting (or at a remote site) while the practitioner obtains test results and consults from healthcare practitioners at distant/other sites.
      • More efficient medical evaluation and management.
      • Obtaining expertise of a distant specialist.

      Possible Risks:

      • As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
      • In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) allow for appropriate medical decision making by the physician and consultant(s);
      • Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
      • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
      • In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;

      By signing this form, I understand the following:

      1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
      2. 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, without affecting my right to future care or treatment.
      3. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My practitioner has explained the alternatives to my satisfaction.
      4. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas.
      5. I understand that it is my duty to inform my practitioner of electronic interactions regarding my care that I may have with other healthcare providers.
      6. 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.
      7. This consent will expire 12 months from the date of signature, unless otherwise specified.

      PATIENT CONSENT TO THE USE OF TELEMEDICINE

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    • KAV MAT Benzodiazepine Policy Agreement

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