Provider Referral Form

At Vancouver Ketamine Infusions Today, we are committed to collaborating with providers to ensure patients receive the highest quality of care. Ketamine infusions, in conjunction with ongoing therapy and medication management, has proven to be a successful and sustainable treatment option for those struggling to find relief.

Click here to download the Provider Referral Form and email it info@vancouverketamineinfusions.com. One of our providers will receive your entry and get in contact shortly. You can also reach Vancouver Ketamine Infusions regarding your patient by filling out the digital form below.

 

Pre-Procedure Instructions

  • You may take your regular medications as you normally would, including the morning of the infusion, unless told otherwise during your consultation.

  • No solid food should be eaten within 6 hours of your infusion, you may drink clear liquids up to 2 hours before your arrival time at the clinic. Failure to comply with this requirement may result in your treatment being canceled and rescheduled.

  • Bring a comprehensive list of all medications and/or substances you are taking or have taken before treatment.

  • You may wear comfortable street clothes during the treatment. You may wish to bring a blanket, pillow, and your favorite music and headphones.

  • Plan to arrive 15 minutes before your scheduled treatment time.

  • Plan to recover for approximately 30 minutes after a 40-45 minute infusion before being released to go home.

  • For infusions that last two to four hours, you should plan on recovering for approximately one hour before being released to go home.

    Post-Procedure Instructions

  • Arrange for someone to drive you home after your infusion.  You will not be able to have treatment without a responsible driver.

  • You should not drive a car or operate machinery on the day of your infusion.

  • You should not use any recreational drugs or alcohol for the next 24 hours.


This document describes how your health information may be used and disclosed and how you may obtain access to this information.  Please review it carefully.

I.OUR PLEDGE REGARDING HEALTH INFORMATION

We understand that your healthcare information is personal.  We are committed to protecting your healthcare information.  We create a record of care detailing the services you receive from us.  We need this record to provide you with quality care and to comply with certain legal requirements.  This notice applies to all of your healthcare records generated by this mental health care practice.  This notice will tell you about how we may use and disclose your healthcare information.  We also explain your rights with regards to your healthcare information and describe certain obligations we have regarding the use and disclosure of your health information.  We are required by law to:

§  Make sure that Protected Health Information (PHI) that identifies you is kept private

§  Give you this Notice of our legal duties and privacy practices with respect to health information

§  Follow the terms of the Notice that is currently in effect

§  We can change the terms of this notice, such changes will apply to all information we have about you.  The new Notice will be available upon request in our office and through our website.

II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe different ways that we use and disclose health information.  For each category of use or disclosure, we will explain what we mean and give examples.  Not every use or disclosure in a category will be listed.  However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

IIa. For Treatment Payment or Healthcare Operations

Federal privacy regulations allow health care providers who have direct treatment relationships with a patient to use or disclose the patient’s personal health information

without the patient’s written authorization to carry out the health care provider’s own treatment, payment, or health care operations.  We may also disclose your PHI for the treatment activities of another health care provider.  This, too can be done without your written authorization.  For example, if a clinician were to consult with another health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in the diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard.  This is because therapists and other health care providers need access to the full record and/or complete information in order to provide the highest quality care.  The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers, and referrals of a patient for health care from one provider to another.

 

IIb.  Lawsuits and Disputes

If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order.  We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.  However, this will only be done if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

1.      Medical notes and records.  We do keep medical records as that term is defined in 45 CFR 164.501.  Any use or disclosure of such records require your authorization except in the following circumstances:

a.     For our use in treating you.

b.     For our use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling.

c.     For our use in defending ourselves in legal proceedings initiated by you.

d.     For use by the Secretary of Health and Human Services to ensure our compliance with HIPAA laws.

e.     Required by law, and the use or disclosure is limited to the requirements of such law.

f.      Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

g.     Required by a coroner who is performing duties authorized by law.

h.     Required to help avert a serious threat to the health and safety of you or others.

2.      Marketing purposes.  We will not disclose your PHI for marketing purposes.

3.     Sale of PHI.  We will not sell your PHI in the regular course of our business.

 

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION

Subject to certain limitations in the law, we can use or disclose your PHI without your consent.  We have to meet many conditions in the law before we can share your information for these purposes.  The following are some of these purposes: 

1.      When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2.     For public health activities.  This includes reporting suspected child, elder, or dependent adult abuse as well as preventing a serious threat to anyone’s health or safety.

3.     For health oversight activities, including audits and investigations.

4.     For judicial and administrative proceedings, including responding to a court or administrative order, although our preference is to obtain authorization from you before doing so.

5.     For law enforcement purposes, including reporting crimes occurring on our premises.

6.     To coroners or medical examiners, when such individuals are performing duties authorized by law.

7.     For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus another form of therapy for the same condition.

8.     Specialized government functions, including ensuring the proper execution of military missions, protecting the President of the United States, conducting intelligence or counterintelligence operations, or helping to ensure the safety of those within or housed within correctional facilities.

9.     For workers’ compensation purposes.  Although our preference is to obtain authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.

10.  Appointment reminders and health-related benefits or services.  We may use and disclose your PHI to contact you to remind you of your appointment with us.  We may also use and disclose your PHI to tell you about treatment alternatives or other health care services that we offer.

11.  For more information, see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

V.  CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT

Disclosures to family, friends, or others.  We may provide your PHI to a family member, friend, or another person that you indicate is involved in your care or the payment of your health care unless you object in whole or in part.  The opportunity to consent may be obtained retroactively in emergency situations.

 

VI. YOU HAVE THE FOLLOWING RIGHTS WITH REGARDS TO YOUR PHI

1.      The Right to Request Limits on the use and disclosure of your PHI.  You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes.  We are not required to agree to your request, and we may say “no” if we believe it would affect your health care.

2.     The Right to Request Restrictions for out-of-pocket expenses paid for in full.  You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or service that you have paid for out-of-pocket in full.

3.     The Right to Choose How We Send PHI to You.  You have the right to ask us to contact you in a specific way—for example, home or office phone, e-mail, or to send postal mail to a different address.  We will agree to all reasonable requests.

4.     The Right to See and Receive Copies of Your PHI.  Other than “psychotherapy notes,” you have the right to receive an electronic or paper copy of your medical record and other information that we have about you.  We will provide you with a copy of your record or a summary of it if you agree to receive a summary within 30 days of receiving your written request.  We may charge a reasonable, cost-based fee for doing so.

5.     The Right to Receive a List of the Disclosures We Have Made.  You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations or for which you have provided us with an authorization to release.  We will respond to your request for an accounting of disclosures within 60 days of receiving your written request.  The list of disclosures you will receive will include all disclosures made within the past six years unless you request a shorter time period.  We will provide this list at no charge, but if you make more than one request in the same calendar year, we may charge you a reasonable, cost-based fee for each additional request.

6.     The Right to Correct or Update Your PHI.  If you believe there is an error in your PHI or that a piece of important information is missing from your PHI, you have the right to request that we amend your PHI.  We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.

7.     The Right to Receive a Paper or Electronic Copy of this Notice.  You have the right to receive a paper copy of this Notice, and you have the right to receive this Notice via e-mail.