Clinical Services

Consent for Clinical Pharmacy Services and Point-of-Care Testing

Please read this entire form carefully. It describes the clinical services and point-of-care tests offered at Downtown Family Pharmacy and asks for your consent to receive these services. If you have any questions, please ask a member of our pharmacy team before signing (discuss in person or call 406.206.2001). This information is confidential and will be managed in accordance with our Notice of Privacy Practices.

1. Introduction and Scope of Services:

I, the undersigned patient (or authorized representative), voluntarily consent to receive clinical pharmacy services from the pharmacists at Downtown Family Pharmacy. I understand that pharmacists at Downtown Family Pharmacy are trained to assess certain health conditions, administer specific services including diagnostic testing and vaccinations (if applicable), and provide treatment or referral as appropriate and as authorized under Montana law.

2. Understanding of Services, Benefits, and Risks:

I understand the potential benefits and risks associated with receiving clinical services and pointof-care testing at a pharmacy.
I have voluntarily chosen to receive these care services.
I understand that if the pharmacy provider determines they cannot provide effective care for my condition, I may be referred to another appropriate healthcare provider (e.g., my primary care physician, urgent care).
I have had the opportunity to ask any questions I might have about the care and services provided to me, as well as alternative options, before giving my consent.

3. Consent for Specific Point-of-Care Testing:

I understand that Downtown Family Pharmacy offers the following point-of-care diagnostic tests. I consent to undergoing collection and testing for the following, as deemed appropriate and discussed with me by the pharmacy provider:

Respiratory Infections:

COVID-19
Influenza A/B (Flu)
Strep A (Streptococcus pyogenes)
Respiratory Syncytial Virus (RSV)

Sample Collection for Respiratory Tests: I understand these tests typically involve a nasal swab, throat swab, or saliva sample.

Urinary Tract Infection (UTI) Screening:

Sample Collection for UTI Screening: I understand this test typically involves a urine sample.

Cardiometabolic Screening:

Lipid Panel (including Total Cholesterol, HDL, LDL, Triglycerides)
Hemoglobin A1c (HbA1c)

Sample Collection for Cardiometabolic Screening: I understand these tests typically involve a fingerstick blood sample.

Important Information Regarding Point-of-Care Testing:

Test Purpose and Limitations: I understand the purpose of these tests is to aid in diagnosis and management. I acknowledge that, as with any medical test, there is a potential for false positive or false negative results.
Follow-Up Responsibility: I understand that the pharmacy staff providing these tests are not acting as my primary medical provider. These tests do not replace comprehensive care from my physician. I assume complete and full responsibility to take appropriate action regarding my test results. I agree to seek medical advice, care, and treatment from my personal medical provider if I have questions, concerns, or if my condition worsens. I understand that failure to seek appropriate medical treatment could result in serious injury or death.
Information Resources: I acknowledge that information fact sheets (such as those provided by the CDC or other health authorities) regarding these tests are available to me upon request or may be provided by the pharmacy.
De-Identified Data Reporting: I understand that de-identified information about my test results (not including any data that could directly identify me) may be compiled by the pharmacy or its partners (e.g., Scripted) to establish local health trends. This aggregated, de-identified information may be shared with public health officials or community leaders.

4. Consent for Treatment and Management:

Following testing and assessment, I consent to receiving appropriate treatment and management recommendations from the pharmacy provider, which may include:

Education about my condition and test results.
Recommendations for over-the-counter products.
If authorized by Montana law and within the pharmacist's scope of practice, prescription of medications.
Referral to my primary care physician or another healthcare provider for further evaluation or treatment.

5. Patient Responsibilities:

I voluntarily assume full responsibility for my choices regarding my health, including any reactions or consequences that may result from the services or tests I receive.
Side Effects/Emergencies: In the event of severe side effects or a medical emergency, I understand I should call 911 or go to the nearest emergency room. For non-urgent side effects or questions, I may call the pharmacy or my doctor.
Accurate Information: I certify that all information I provide to the pharmacy, including my medical history and information regarding eligibility for treatment, is accurate and complete to the best of my knowledge.

6. Disclosure of Health Information & Notice of Privacy Practices:

I understand that Downtown Family Pharmacy may be required to, or may voluntarily, disclose my health information related to these services as permitted or required by law. This may include disclosure to:

My designated healthcare providers.
My insurance plan (for payment purposes).
Public health authorities (e.g., for reportable diseases like COVID-19 or Influenza).
Health systems or hospitals involved in my care.
State or federal registries as required.

I understand that Downtown Family Pharmacy will use and disclose my protected health information (PHI) as set forth in the pharmacy's Notice of Privacy Practices. I acknowledge that a copy of the Notice of Privacy Practices is available to me upon request from the pharmacy team.

7. Financial Responsibility & Insurance Authorization:

Acceptance of Financial Responsibility: I understand and agree that I am financially responsible for all charges for any and all services rendered at Downtown Family Pharmacy. This includes any medical service, consultation, testing, screening, or prescribed medication (if applicable) ordered or provided by the pharmacy staff.
Insurance: I authorize Downtown Family Pharmacy to release necessary information to Medicare, Medicaid, or any other third-party payer (my insurance company) to request payment of authorized benefits on my behalf. I certify that the information I have provided about my insurance coverage is correct.
Understanding of Coverage: I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment by my insurance company. I am responsible for any unpaid balance, including co-payments, deductibles, co-insurance, and charges for services not covered or disallowed by my insurance carrier.

8. Consent on Behalf of Minors or Other Individuals:

If I am signing this consent form on behalf of another individual (including a minor under 18 years of age for whom I am the legal guardian or have legal authority to make healthcare decisions), I attest that I have the legal authority to consent to these clinical services and point-of-care tests for that individual. All references to "I" or "my" in this document shall be understood to refer to the patient for whom I am signing.

9. Patient Acknowledgement and Electronic Signature:

I have read this entire "Consent for Clinical Pharmacy Services and Point-of-Care Testing" form, or it has been read to me.
I have had the opportunity to ask questions about its content, the services offered, the tests, and any potential risks or benefits, and my questions have been answered to my satisfaction.
I understand all the statements contained within this form.

(updated 05/06/2025)

I have read, understood, and agree to the Consent for Clinical Services.

Notice of Privacy Practices (NPP)

NOTICE OF PRIVACY PRACTICES

7/1/2015

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

As part of the federal Health Insurance Portability and Accountability Act of 1996, known as HIPAA, the Facility has created this Notice of Privacy Practices (Notice). This Notice describes the Facility’s privacy practices and the rights you, the individual, have as they relate to the privacy of your Protected Health Information (PHI). Your PHI is information about you, or that could be used to identify you, as it relates to your past and present physical and mental health care services. The HIPAA regulations require that the Facility protect the privacy of your PHI that the Facility has created or received.

This Facility will abide by the terms presented within this Notice. For any uses or disclosures that are not listed below (including Marketing and Selling of PHI), the Facility will obtain a written authorization from you for that use or disclosure, which you will have the right to revoke at any time, as explained in more detail below. The Facility reserves the right to change the Facility’s privacy practices and this Notice.

HOW THE FACILITY MAY USE AND DISCLOSE YOUR PHI

The following is a list of circumstances in which the Facility is permitted, by law, to use and disclose your PHI.

Uses and Disclosures of PHI for Treatment: We will use the PHI that we receive from you to fill your prescription and coordinate or manage your health care.

Uses and Disclosures of PHI for Payment: The Facility will disclose your PHI to obtain payment or reimbursement from insurers for your health care services.

Uses and Disclosures of PHI for Health Care Operations: The Facility may use the minimum necessary amount of your PHI to conduct quality assessments, improvement activities, and evaluate the Facility workforce.

The following is an accounting of additional ways in which the Facility is permitted or required to use or disclose PHI about you without your written authorization:

Uses and disclosures as required by law: The Facility is required to use or disclose PHI about you as required and as limited by law.
Uses and disclosure for Public Health Activities: The Facility may use or disclose PHI about you for a public health authority that is authorized by law to collect or receive PHI for the purpose of preventing or controlling disease, injury, or disability. This includes, but may not be limited to, adverse effects of drugs, foods, nutritional supplements and other products as required by law.
Uses and disclosures for victims of abuse, neglect or domestic violence: The Facility may use or disclose PHI about you to a government authority if it is reasonably believed you are a victim of abuse, neglect or domestic violence.
Uses and disclosures for health oversight activities: The Facility may use or disclose PHI about you to a health oversight agency for oversight activities authorized by law. These investigations, inspections as necessary for licensure, compliance with civil laws, or other activities the health oversight agency is authorized by law to perform.
Disclosures for judicial and administrative proceedings: The Facility may disclose PHI about you to individuals involved in your care.
Disclosures for judicial and administrative proceedings: The Facility may disclose PHI about you in the course of any judicial or administrative proceeding in response to an order of the court or as otherwise authorized by law.
Disclosures for law enforcement purposes: The Facility may disclose PHI about you to law enforcement officials for authorized purposes as required by law or in response to a court order or subpoena.
Uses and disclosures about the deceased: The Facility may disclose PHI about a deceased, or prior to, and in reasonable anticipation of an individual’s death, to coroners, medical examiners, and funeral directors.
Uses and disclosures for cadaveric organ, eye or tissue donation purposes: The Facility may use and disclose PHI for the purpose of organ donation and transplantation.
Uses and disclosures for research purposes: The Facility may use and disclose PHI about you for research purposes with a valid waiver of authorization for an institutional review board or a privacy board. Otherwise, the Facility will request a signed authorization by the individual for all other research purposes.
Uses and disclosures to avert a serious threat to health or safety: The Facility may use or disclose PHI about you, if it believed in good faith, and is consistent with any applicable law and standards of ethical conduct, to avert a serious threat to health or safety.
Uses and disclosures for specialized government functions: The Facility may use or disclose PHI about you for specialized government functions including; military and veteran’s activities, national security and intelligence, protective services, medical suitability determinations, and correctional institutions and law enforcement custodial situations.
Disclosure for workers’ compensation: The Facility may disclose PHI about you as authorized by and to the extent necessary to comply with workers’ compensation laws or programs established by law.
Disclosures for disaster relief purposes: The Facility may disclose PHI about you as authorized by law to a public or private entity to assist in disaster relief efforts and for family and personal representative notification.
Disclosure to business associates: The Facility may disclose your PHI to the Facility’s business associates for services that they may provide to or for the Facility to assist the Facility to provide quality health care. To ensure the privacy of your PHI, we require all business associates to apply appropriate safeguards to any PHI they receive or create.

OTHER USES AND DISCLOSURES

The Facility may contact you for the following purposes:

Information about treatment alternatives: The Facility may contact you to notify you of alternative treatments and/or products.
Information about health-related benefits and services: The Facility may use your PHI to notify you of benefits and services the Facility provides.
Fundraising: If the Facility participates in fundraising activities, the Facility may use demographic PHI to send you a fundraising packet, or the Facility may disclose demographic PHI about you to its business associate or an institutionally related foundation to send you a fundraising packet. No further information will be sent to you without your prior written authorization. Any fundraising communication will provide a clear and conspicuous opportunity for you to opt-out of all future fundraising activities.

FOR ALL OTHER USES AND DISCLOSURES

The Facility will obtain a written authorization from you for all other uses and disclosures of PHI, and the Facility will only use or disclose PHI pursuant to such an authorization. In addition, you may revoke such an authorization in writing at any time. To revoke a previously authorized use or disclosure, please contact Josh Fisher to obtain a Request for Restriction of Uses and Disclosures.

YOUR HEALTH INFORMATION RIGHTS

The following is a list of your rights with respect to your PHI. Please contact Josh Fisher for more information about the below.

The right to request restrictions of the Facility’s uses and disclosures of your PHI: You have the right to request additional restrictions of the Facility’s uses and disclosures of your PHI. The Facility is not required to accommodate a request, except that the Facility is required to agree to a request to restrict disclosures to a health plan for purposes of carrying out payment or health care operations if the PHI pertains solely to a health care item or service for which you have paid out of pocket in full.
The right to have your PHI communicated to you by alternate means or locations: You have the right to request that the Facility communicate confidentially with you using an address or phone number other than your residence. However, state and federal laws require the Facility to have an accurate address and phone number in case of emergencies. The Facility will consider all reasonable requests.
The right to inspect and/or obtain a copy your PHI: You have the right to request access and/or obtain a copy of your PHI that is contained in the Facility for the duration the Facility maintains PHI about you. There may be a reasonable cost-based charge for photocopying documents. You will be notified in advance of any such charges.
The right to amend your PHI: You have the right to request an amendment of the PHI the Facility maintains about you, if you feel that the PHI the Facility has maintained about you is incorrect or otherwise incomplete. Under certain circumstances, we may deny your request for amendment. If we do deny the request, you will have the right to file a dispute statement with our privacy officer. We will provide you with a written denial notice. You may also ask the Secretary, United States Department of Health and Human Services (“HHS”), or their appropriate designee to review a denial.
The right to receive an accounting of disclosures of your PHI: You have the right to receive an accounting of certain disclosures of your PHI made by the Facility.
The right to receive additional copies of the Facility’s Notice of Privacy Practices: You have the right to receive additional paper copies of this Notice upon request. If you initially receive the Notice electronically.
Notification of Breaches: You will be notified of any breaches that have compromised the privacy of your PHI.

REVISIONS TO THE NOTICE OF PRIVACY PRACTICES

The Facility reserves the right to change the terms of this Notice and make the new revised version applicable to all PHI received prior to its effective date. The Facility will also post the revised version of the Notice in the Facility.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with the Facility and/or to the Secretary of HHS, or his designee. If you wish to file a complaint with the Facility, please contact Josh Fisher. If you wish to file a complaint with the Secretary, please write to: http://www.hhs.gov/ocr/office/about/rgn-hqaddresses.html. The Facility will not take any adverse action against you as a result of your filing of a complaint.

CONTACT INFORMATION

If you have any questions on the Facility’s privacy practices or for clarification on anything contained within the Notice, please contact:

406 Rx PLLC
DBA: Downtown Family Pharmacy
Josh Fisher, Privacy Officer
PO Box 1469
Columbus, MT 59019
(406) 780-8016

I acknowledge that I have received and had the opportunity to review the Notice of Privacy Practices.

Digital Signature

Please type your full name to electronically sign these documents.

By typing my name, I am providing a legally binding electronic signature, confirming my agreement and acknowledgement of the forms above.

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