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I consent to evaluation and treatment via telehealth (video/phone) by Kamsi Healthcare Corp. For emergencies, call 911 or go to the nearest ER. Initials:
I consent to clinically appropriate prescribing of scheduled/controlled medications through telehealth and agree to required safety monitoring (follow-ups, PDMP checks, UDS/pill or film counts when requested). Initials:
I authorize Kamsi Healthcare Corp. to contact me by email, text message, and phone call (including voicemail) for non-emergency purposes such as scheduling, reminders, care coordination, forms, and billing/administrative communication. I understand these methods may not be fully secure and are not for emergencies.
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I acknowledge the Notice of Privacy Practices was offered. Initials:
If I receive SUD services, I authorize Part 2-protected info use/disclosure for Treatment/Payment/Operations as permitted by law; revocable in writing (except where already relied upon). Initials:
I authorize release of information only as specified in a separate ROI form (HIPAA/Part 2 as applicable); revocable in writing (except where already relied upon). Initials:
I consent to use of AI-assisted documentation (AI scribe) to help draft my visit note. My clinician remains responsible for my care and will review/edit for accuracy. I may decline and still receive care. Initials:
If I receive Medication-Assisted Treatment, I agree to follow the MAT plan and safety requirements, including attending scheduled visits, taking medication only as prescribed, not sharing/selling medication, and completing monitoring when requested (e.g., UDS, PDMP checks, pill/film counts). Initials:
I agree I am responsible for charges not covered by insurance (including copays, coinsurance, deductibles, self-pay balances, and no-show/late-cancel fees if applicable). I authorize billing to my insurer and understand unpaid balances may be billed to me. Initials:
I consent to the collection and processing of my personal information and, where applicable, health-related information, including any data I submit on behalf of others. This is for the purpose of evaluating or fulfilling my request, in accordance with the
Privacy Policy
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