COLUMBIA COUNTY VOLUNTEERS IN MEDICINE CLINIC, INC.

310 East 3rd Street  P.O. Box N          Mifflinville, PA 18631         570-752-1780

 

PATIENT SERVICE AGREEMENT

 

Our goal is to improve the health of the medically underserved in Columbia County.  Our volunteers will provide those services with dignity and respect.  In return, we ask that you agree to be courteous to those volunteers that are attempting to help you.  We also ask that you are courteous to the other patients in the clinic.  We also ask that you realize that CCVIM is a place of business and we ask that you dress appropriately (shoes and shirts are required).

 

Patient name/initials/DOB (please print)____________________________________

We ask you to agree to the following and initial each line.

  

CLINIC SERVICES

  1.  _____I understand and agree the goal of CCVIM is to provide primary health care for health problems. 
  2. _____I understand and agree that CCVIM may provide a consultation with a volunteer specialist, but not pay for the recommendations of the specialist.
  3. _____I understand and agree that CCVIM may provide me with:
    • Ø      Physician and nursing office visits
    • Ø      Case Management
    • Ø      Limited prescriptions and/or medications
    • Ø      Blood testing and diagnostics                                         
  4. _____I understand and agree that CCVIM will NOT PROVIDE me with:
    • Ø      SURGERY
    • Ø      PRENATAL CARE OR DELIVERY OF BABIES
    • Ø      TREATMENT OF HIV/AIDS
    • Ø      EMERGENCY TREATMENT
    • Ø      IMMUNIZATIONS (except pneumonia, tetanus, flu –WHEN AVAILABLE)
    • Ø      COLONOSCOPY FOR SCREENING PURPOSES
    • Ø      OTHER SERVICES THAT ARE OUTSIDE OF THE SCOPE OF PRIMARY CARE                                                          
  5. _____I understand and agree that CCVIM may or may not provide me with the following depending on the available resources:
    • Ø      CT or MRI scans
    • Ø      SLEEP STUDIES
    • Ø      FINE NEEDLE ASPIRATIONS

TREATMENT:

  1. _____I request CCVIM to provide me with medical and/or case management services.
  2. _____I agree to follow the recommendations for any medical diagnosis as recommended by CCVIM staff.
  3. _____I understand and agree that at any time I have the option to see medical care elsewhere at my OWN EXPENSE.
  4. _____I agree to take all prescribed medications as directed and will tell CCVIM volunteers if there are any side effects of the prescribed medications.  I agree to take and not stop medications unless I have discussed this with the CCVIM medical volunteers.  If I fail to follow the recommendations of the medical staff, this could be cause for dismissal from clinic services.
  5. ____ I agree to have health care students participate in my care at the CCVIM clinic.  There will be supervisors of these students and students are bound by confidentiality laws.

MEDICATIONS

  1. ____I agree that CCVIM may not provide me with all medications that I need.
  2. ____I understand and agree that CCVIM will NOT provide me with expensive mental health or epilepsy medications, birth control pills, etc..
  3. ____I understand and agree that I will receive a maximum of a 30-day supply of medication, unless there are special circumstances and CCVIM medical volunteers have approved my request.
  4. ____I agree to request all refills at least ONE WEEK IN ADVANCE.
  5. ____I understand and agree that there will be NO NARCOTICS ISSUED FROM THE CLINIC, EITHER BY SAMPLES OR BY A WRITTEN PRESCRIPTION. 

APPOINTMENTS

  1. ____I understand and agree that I will be seen by appointment only.  If I have an urgent concern such as strep throat, I will call to see if CCVIM can provide me with an appointment.  I may be referred to an emergency room for care, if that happens; I will pay for the Emergency Room visit.
  2. ____I understand and agree that if I believe that my concern is potentially life threatening, such as chest pain, severe pain, etc., I should seek services at the nearest emergency room at my own expense.  CCVIM DOES NOT PAY FOR EMERGENCY CARE.
  3. ____I agree to call for an appointment before coming to CCVIM.  I will not show up without an appointment.
  4. ____I agree to call at least 24 hours in advance if I am unable to keep any scheduled appointment at CCVIM or referred provider’s office.  FAILURE TO DO SO WILL JEOPARDIZE MY ABILITY TO RECEIVE FUTURE CCVIM SERVICES AND/OR TREATMENT.
  5. ____I understand and agree that there may be times that the clinic will have to reschedule my appointment due to inclement weather or other things outside of CCVIM’s control.
  6. ___ I understand and agree to keep all appointments with CCVIM DOCTORS, CASE MANAGERS, AND NURSES.  FAILURE TO KEEP ANY 2 APPOINTMENTS IN A 6 MONTH PERIOD WILL RESULT IN MY DISMISSAL FROM CCVIM SERVICES FOR 3 MONTHS.  IF THIS HAPPENS TWICE, I WILL BE PERMANENTLY DISMISSED FROM SERVICES.
  7. ____I agree to keep all appointments with SPECIALISTS REFERRED TO BY CCVIM.  FAILURE TO KEEP ANY 1 APPOINTMENT WILL RESULT IN DENIAL OF FURTHER SPECIALIST SERVICES.  ALSO, I WILL BE ABLE TO ONLY RESCHEDULE ONCE WITH THE SPECIALIST, AFTER THAT THE SPECIALIST CAN DECIDE IF I AM ALLOWED TO RESCHEDULE AGAIN.  I WILL CALL THE SPECIALIST’S OFFICE TO CANCEL OR RESCHEDULE.

RESPECT AND SAFETY

  1. ____I agree to be courteous to CCVIM staff and volunteers, as well as to other CCVIM patients.  PROFANITY, ABUSIVE LANGUAGE OR ACTIONS, THREATS OR VIOLENCE WILL NOT BE TOLERATED AND WILL BE GROUNDS TO BE DISMISSED FROM THE CLINIC.
  2. ____I agree to dress appropriately for my CCVIM and specialist appointments.
  3. ____I agree not to come to CCVIM clinic for an appointment under the influence of drugs and/or alcohol.  I UNDERSTAND I WILL NOT BE SEEN IF UNDER THE INFLUENCE OF THESE SUBSTANCES.
  4. ____I agree not to bring WEAPONS OF ANY KIND TO THE CLINIC.  THIS WILL BE GROUNDS FOR DISMISSAL FROM THE CLINIC AND ANY FUTURE APPOINTMENTS.

FINANCIAL

  1. ____I understand and agree that to be eligible for CCVIM services I must live in Columbia County, have a household gross income at or less than 200% of the current yearly Federal poverty guidelines and have NO INSURANCE COVERAGE UNDER ANY OTHER HEALTH INSURANCE PLANS FOR THE SERVICES PROVIDED BY CCVIM.

  2. ____I understand and agree that CCVIM is NOT AN INSURANCE PROGRAM AND I AGREE NOT TO LIST CCVIM AS A PAYOR if I go to the emergency room or am hospitalized.
  3. ____I understand and agree if I knowingly produce false information in order to receive medical treatment, I will be responsible for the cost of the treatment I have received, including any specialty visits, diagnostic studies, medications, etc.  I also may be subject to prosecution.
  4. ____I agree to meet with a CCVIM case manager to discuss insurance programs and community resources for which I may be eligible.
  5. ____I agree to apply for health services I may be eligible for and will provide proof of acceptance or denial to the CCVIM volunteers.
  6. ____I agree to provide proof of income at least annually and more often as the guidelines are changed, including possibly at least monthly.  The income list would include federal income tax returns and W2’s.

 

Patient Name (please print):_______________________________________________

We ask you to agree to the following and initial each line.

 

CONFIDENTIALITY

______I understand that all information given to CCVIM will be kept confidential and will not be shared with my employer, my family, or other persons without my authorization except when CCVIM is legally required to do so.

 

 

MEDICATION ASSISTANCE PROGRAMS

CCVIM is a resource for qualifying residents to obtain medication from Patient Assistance Programs (PAP) sponsored by many pharmaceutical companies.  When an applicant meets the Clinic’s eligibility requirements, the clinic applies at regular intervals to these companies on the applicant’s behalf to obtain prescription medication.  In most cases, the patient’s signature is required and in all cases the prescribing physician’s signature is required on each application form.

 

By signing this agreement, you, the patient, request and give your permission to the Clinic’s Clinical Director, or their designee, to sign your name on your order form(s).  Your name will be signed only on medication orders that are specifically for you, as prescribed by your physician.

 

AGREEMENT:

I acknowledge that my signature at the end of this agreement indicates that I hereby give permission to CCVIM clinic Clinical Director or their designee, to sign my name to Patient Assessment applications for medications prescribed by my physician.  I understand that I may revoke this agreement at any time and assume responsibility for signing my own forms.    _________

 

CONCERNS AND COMPLAINTS

I understand that I may contact the Clinic Director, Monday – Friday, 9:00 AM – 5:00 PM. at the clinic number.        ______

 

AUTHORIZATION

I have read this agreement and agree to all of the conditions stated on the previous pages.  I understand failure to comply will result in CCVIM Clinic services no longer being available to me.  I have received a copy of this agreement and have had the opportunity to ask questions.  ________

 

Patient Signature(Parent/Guardian signature if patient is under 18):

 

__________________________________________________________   Date:___________

 

Witness to signature:  ______________________________________   Date:__________