Russell Healthcare
FlowerMedical and FlowerCardMed are marketing names for Russell Healthcare Consulting, LLC.

FlowerMedical HIPAA Notice of Privacy Practices and Disclosure

We understand that health information about you and your health is personal. We are committed to protecting health information about you. We create a record of care and services you receive from us. We need this record to provide you with Quality Care as well as to comply with certain legal requirements. This notice applies to all of the records of your care generated by this office, whether initiated by your primary care provider or other providers working with FlowerMedical.

Below describes your rights to the health information we keep about you and describes certain obligations we have regarding the use and disclosure of your health information.

We are required by law:
Make sure that health information that identifies you is kept private
Give you this notice of our legal Duty and privacy practices with respect to your health information about you
Follow the terms of the Notice that is currently in effect

How we may use and disclose information about you:
For treatment
For payment
For healthcare operations
For appointment reminders

As required by law your rights regarding health information about you:
Right to inspect and copy
Right to amend
Right to accounting of disclosures
Right to request restrictions
Right to request confidential communications
Right to a paper copy of the Notice (Full Notice available upon request)

Change to the Notice: We reserve the right to change this Notice at any time. We will post a copy of the current notice in our facility with a current effective date on the first page.

Complaints: If you believe that your privacy rights have been violated, you may file a complaint with us. All complaints must be in writing. Please contact the CEO of Russell Healthcare Consulting, LLC to file a complaint.

If you have chosen any full service option through FlowerMedical or any of its constituents, you acknowledge and agree that FlowerMedical and its constituents shall not be liable for any errors in submission, and you hereby release and waive any claims against the aforementioned arising from such errors.  Also, at any time you may request a revision to your registration(s) to include your personal email.

MASSACHUSETTS RESIDENT PATIENT RELEASE AND ACKNOWLEDGMENT

I understand and acknowledge:
The purpose of this visit to FlowerMedical is for consultation and evaluation by a FlowerMedical health care provider to determine if I am medically qualified for a MMJ (medical marijuana) card issued by the Massachusetts Cannabis Control Commission (CCC) for the medical use of marijuana pursuant to Massachusetts laws and regulations. No clinical diagnoses are provided. Also, I believe my medical condition(s) is chronic and debilitating thus significantly affecting and decreasing my quality of life as well as my daily activities.
The FlowerMedical provider(s), staff, agents and/or representatives are not providing, dispensing, or encouraging me to obtain or secure a MMJ card. I asked for this visit.
The FlowerMedical provider(s) and/or staff are addressing only specific aspects of my medical care and conditions as consultation, and unless otherwise stated in writing, are in no way whatsoever establishing themselves as primary care, specialty care, or private health care providers to me. I do not and will not hold FlowerMedical providers, staff, agents, and/or representatives responsible or liable in any way whatsoever for my use of MMJ and any of its affects or side effects, or any harm resulting to me or others as a result of my MMJ use.
FlowerMedical has informed me that MMJ is an alternative to other recommended treatments for multiple conditions. I am aware of the potential side effects and risks of both short and long term use of MMJ.
I am aware that MMJ is a self administered medication and further agree that if I elect to use MMJ, I will use it strictly for the treatment of my authorized medical condition(s) and it will be at my sole discretion. I also agree to immediately cease self administration of MMJ if I experience any side effects or ill effects from MMJ use as well as contact both my PCP and FlowerMedical as soon as possible. I will also stop MMJ use if at any time I experience any severe side effects or ill effects including but not limited to: respiratory (breathing) problems, chest pain, heart problems, changes in my normal sleeping patterns, extreme fatigue, increased irritability, or I begin to withdraw from friends/family or have to thoughts of causing harm to myself or others. In any of these instances, I agree to contact 911 for immediate and emergent care.
Using MMJ while under the influence of alcohol is not recommended under any circumstances nor is MMJ intended to be used in conjunction with alcohol. I shall under no circumstances drive a car or operate machinery while using MMJ.

I will not use MMJ within 1000 feet of a school or daycare center. I intend to use MMJ in privacy.
I am not on probation for, or have legal matters pending for a drug related offense.
FlowerMedical will use the Massachusetts Prescription Monitoring Program prior to the issuance of the registration PIN number from the CCC.
I am NOT an on-duty agent of law enforcement for the local state or federal government or private group and/or in consultation with FlowerMedical for the purpose of investigation or entrapment.
I am NOT a member of the media, newspaper, or press and that all communication is strictly confidential. I will NOT record, film, or photograph any portion of the consult with FlowerMedical, nor do I possess any recording equipment. FlowerMedical DOES NOT approve of any such action.
FlowerMedical will provide a certification for MMJ which will lead to a Registration/PIN number by the CCC. Registration through the CCC is at the discretion of CCC. Problems with registering once provided a PIN number by FlowerMedical should be resolved with CCC.
FlowerMedical’s CCC certifying medical provider will provide Registration/PIN which would enable me to obtain a registration through CCC. FlowerMedical provides full service option for an additional fee. If I am unable to complete the registration through CCC, FlowerMedical may be able to assist me with this registration process for an additional fee even if I did not choose this at my initial consultation.
I have spoken with my PCP regarding my plan to use MMJ for the authorized medical condition. I will provide and allow FlowerMedical full release of my medical records regarding these authorized chronic and debilitating conditions and/or others as needed.
All of the information, medical information, and medical history of my chronic and debilitating conditions I have provided, discussed, and/or written down for FlowerMedical is true and to the best of my knowledge. Furthermore, if FlowerMedical subsequently learns that any of the information I have furnished is false or misleading to the CCC registration for an MMJ card, said card may no longer be valid and I agree to promptly contact FlowerMedical and provide additional accurate information.
No confidential information will be released by FlowerMedical without my consent, unless required by HIPAA or due process of law, government, or licensed authorities. I also authorize authorities related to my possession or use of MMJ.
I am not pregnant but if I become pregnant, I will discontinue use of any form of MMJ as its continued use may be detrimental to the fetus.

FlowerMedical and FlowerCardMed are marketing names for Russell Healthcare Consulting, LLC.

The above is a copy of the acknowledgement required for any and all patients of FlowerMedical and must be reviewed prior to each visit.  You may view and acknowledge here.