Last updated: September 23, 2020
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CONSENT TO TREAT: You acknowledge and agree that you have requested to receive medical treatment and services from Heal Doctors (the “Practice”), and you consent to the rendering of medical treatment and services as considered necessary and appropriate by your treating provider. You have the right to decline treatment and services at any time, but you may be responsible for paying for services already rendered. You also acknowledge that no assurances or guarantees have been made to you by the Practice or any of the Practice’s staff concerning the outcome and/or results of any medical treatment or services.
In-Person Visits: The Practice provides mobile, in-person visits at patient-specified locations for both adult and pediatric patients. Available services for in-person visits include scheduled, primary-care services as well as well as short-noticed, non-emergency, sick-care services to treat illnesses or minor injuries. For example, during an in-person visit your treating provider may administer vaccinations, perform wellness exams and/or annual physicals, assess and treat chronic conditions, assess and treat illness like the common cold, flu, stomach aches or ear infections, or assess and treat minor injuries. Please note, the Practice does not provide general obstetrics services or any emergency services.
Telehealth Services : The Practice also provides non-emergent, telehealth and remote patient monitoring (“RPM”) services, whereby patients may receive limited healthcare services without in-person contact between the patient and provider. Telehealth services and RPM services are available only in limited circumstances, and only at the Practice’s sole discretion. Telehealth services are not intended to replace the need for in-person medical treatment and evaluation. By signing this consent form, you are also agreeing to use of telehealth services. However, at any time you may opt not to receive telehealth services.
Under certain limited circumstances, your treating provider (and/or the Practice) may determine, in his or her best judgment, that he or she is unable to provide medical treatment and services to you, based on information received or conduct occurring during the course of a visit. However, in no case will the Practice or any of its staff make such a determination based on any patient’s sex, sexual orientation, gender-identity, race, creed, color, religion, national origin or disability, or status in any other protected class.
THE PRACTICE DOES NOT PROVIDE EMERGENCY MEDICAL CARE: If you have an emergency, such as chest pain, severe shortness of breath, severe headache or bleeding, call 911 or proceed directly to the nearest hospital emergency room.
PRESCRIPTION POLICY: You understand and acknowledge that no assurances or guarantees will made by the Practice or any of the Practice’s staff concerning the prescription of any medication(s). Your treating provider, based on his or her professional judgment, is solely responsible for determining the clinical appropriateness and necessity, or lack thereof, for any prescribed medication(s). At the time of prescribing any medication(s), your treating provider will advise you on known risks and potential benefits of the medication(s).
You further understand that Scheduled II, III, or IV drugs, or any other drug that is reasonably determined by the prescribing provider and/or the Practice to pose a risk of abuse or diversion (collectively, these drugs are referred to herein as “Controlled Medications”), will only be prescribed to established and existing patients who use the Practice as their primary care provider, and even then only when the prescribing provider determines such medications to be medically appropriate after a complete in-person evaluation to assess the condition for which the medications are indicated. The Practice never requires or guarantees that any Controlled Medication will be prescribed or continued.
PEDIATRIC VACCINATION POLICY: The Practice strictly follows the vaccination schedules put out the American Academy of Pediatrics (AAP) and Centers for Disease Control (CDC). The Practice will not treat pediatric patients who are not adequately vaccinated in compliance with these standards. Prior to a child’s visit the Practice will require a copy of the child’s immunization record showing the child is adequately vaccinated.
For children who are not adequately vaccinated at the time of the patient’s first appointment with the Practice, the Practice will only treat the child if the guardian(s) commit to a formal vaccination plan with the Practice that will bring the child’s immunizations into compliance with the AAP schedules. The Practice is committed to helping families understand that vaccinations are both safe and effective. If the Practice arrives at a visit where the child’s immunizations are not in compliance with these standards and the child’s guardian will not commit to bringing the child’s immunizations into compliance with the AAP’s schedules, then the Practice will not treat the child and will terminate the physician-patient relationship. In addition, if the Practice arrives at a visit and the child’s guardian is not present for a first-time visit or a well child visit for vaccinations, we will charge a $159 cancelation fee.
For those families who are not willing to commit to vaccinating their children, the Practice requests that you seek medical care at another medical provider who shares more similar beliefs with your family.
SUBSEQUENT CARE & COORDINATION WITH YOUR PRIMARY CARE PROVIDER: If the Practice is not your primary care provider, it is your sole responsibility to follow through with your primary care provider on any medical conditions or potential abnormalities detected or not detected by the visit, and to obtain a medical examination by your primary care provider related to the findings, or lack of findings, of this visit.
RELATIONSHIP WITH GET HEAL INC.: The Practice has entered into an administrative services agreement with Get Heal, Inc. (“HealTM”), a separate and independent management services company, pursuant to which Heal provides the Practice with certain operational, management, technology and other related services, including licensing out HealTM’s propriety online and mobile application (the “HealTM Application”). The Practice uses HealTM and the HealTM Application for various purposes, including to intake requests for services, schedule visits, facilitated communications, manage patient records, process claims, and support the Practice’s telehealth services. HealTM is not a medical provider and does not provide any medical services.
You understand and agree that by downloading, registering and/or using the HealTM Application alone does not create a patient relationship with the Practice. A patient relationship with the Practice is only established when you have actually been treated by one of the Practice’s providers. In addition, you acknowledge and agree that you have selected to receive services from the Practice and that no third-party, including HealTM, has referred, suggested or recommended the Practice to you.
EQUITABLE ACCESS & NON-DISCRIMINATORY CARE POLICY: It is the Practice’s policy to make all commercially reasonable efforts to provide accommodations that will allow seniors and people with disabilities to request and receive equitable access and non-discriminatory medical care. As such, to the extent practicable and/or required by law, the Practice’s operations align with the standards set by Section 504 of the 1973 Rehabilitation Act, the Americans with Disabilities Act, as amended (ADA), and other applicable state laws and regulations that prohibit discrimination on the basis of disability. However, the Practice does not have any medical office open to the public or any other public facility where the Practice provides medical services. You understand and agree that the practice’s mobile care delivery model means that the Practice has no control over any physical accommodations at the specific locations where you may request and/or receive medical services.
PAYMENT FOR SERVICES: The Practice generally charges on a fee-for-service basis for the services it provides, or by some other fee-schedule negotiated between the Practice and its contracted health plans (the “Service Fee”). Any Service Fees, or portion thereof that is your financial responsibility must be made by credit card through the HealTM Application. When necessary to accommodate patients with disabilities, the Practice may accommodate payment telephonically. The Practice does not accept cash payments from patients or accept any in-person payments. If timely payment is not made, the Practice may engage third parties to collect any outstanding payments. If you are a member of an insurance plan that contracts with the Practice as an in-network provider, and your insurance coverage has previously been verified, the Practice will bill the insurance plan for the portion of the Service Fee for which it is responsible. The Practice is a participating medical practice in the Medicare Program and accepts assignment for Medicare claims. If you are a Medicare beneficiary, the Practice accepts the Medicare approved amount as full payment for covered services. You will be responsible for any applicable copayments or deductibles, and your credit card will be charged accordingly. THE PRACTICE DOES NOT PARTICIPATE IN MEDICAID. BY SIGNING BELOW, YOU ACKNOWLEDGE THAT YOU ARE NOT A MEDICAID OR MEDI-CAL BENEFICIARY.
Please be aware that some – and perhaps all – of the services you receive may not be covered or not considered reasonable or necessary by your health insurance plan. The balance of your claim is your financial responsibility, whether or not your health insurance plan pays your claim. It is your responsibility, as the insured, to determine if the Practice is a network provider and how your benefits apply.
RETENTION OF RECORDS: The Practice shall retain health care records for at least six (6) years after their receipt or production, unless a longer period is required by law (e.g., for records of minors). The Practice may destroy health records once it is no longer required to retain them.
COORDINATION WITH HEALTH RECORDS AND HEALTH DATA: In an effort to gain a more complete picture of your health and help avoid unnecessary testing and duplicated efforts, the Practice supports coordinating access to your health records and health data that may be created by various third-party sources before, after and/or in between your visit(s). This may include access to (1) your patient health records from other providers and/or (2) your electronic health data created by your use of different wellness, fitness or medical devices.
In an effort to streamline this coordination via wireless transmission, you can connect your account in the HealTM Application with other third-party platforms and/or products that will share your information with the HealTM Application. The Practice will be able to see any of your records and data that are shared with the HealTM Application. Your information will only be shared with the Practice in this manner as long as your account remains connected. Your decision to connect your accounts is completely voluntary and you may disconnect from third-party platforms or products at any time.
Because the Practice is not affiliated with any applicable third-parties, it makes no promise that third-party platforms or products will be fault free. Further, the Practice is not responsible for the accuracy of your health records or health data that are created by any third-parties.
ASSIGNMENT OF BENEFITS; AUTHORIZED REPRESENTATIVE: In exchange for and in connection with any and all of the service(s) provided to you by the Practice, by signing below you hereby irrevocably and expressly request that payment of authorized insurance benefits be made on your behalf to the Practice for services furnished to you. In addition, by signing below, you hereby designate the Practice as your duly authorized representative in connection with all matters arising from or relating to the services provided, and you agree to cooperate with and take all steps necessary to effectuate, perfect, confirm or validate the assignment of benefits and/or authorization of the Practice as your authorized representative, as addressed herein.
INDEMNIFICATION: You acknowledge that you shall be liable for, and shall indemnify, defend and hold harmless the Practice from any and all liability, loss, claim, lawsuit, injury, cost, damage or expense whatsoever (including reasonable attorneys’ fees and court costs) arising out of, incident to or in any manner occasioned by (1) the performance or nonperformance of any duty or responsibility by patient, (2) any tortious acts committed by you or any other person at your residence or other location of the visit, and (3) any damages resulting from any defects at your residence or location, but only to the extent, and only in such amount, that such liability, loss, claim, lawsuit, injury, cost, damage or expense is not covered and paid by third party insurance. The foregoing indemnification provision shall in all instances be deemed to be subordinate to any third-party insurance coverage that may cover all or any portion of any indemnification claim, including without limitation the patient’s homeowner’s insurance policy, as applicable.
DISCLOSURE OF PROVIDER INFORMATION & PATIENT GRIEVANCES: All the Practice’s clinicians are licensed, certified or otherwise permitted to provide medical services in the state of where medical services are provided. Your treating provider’s information, including name, highest level of academic degree, specialty, license status, and license number, and board certification (where applicable) are available through the HealTM Application.
Should you have any questions, comments, feedback or grievances concerning your treating clinician, the Practice’s clinical team or other staff, and/or the treatment you received, you may always reach out directly to the Practice at Support@Heal.com.
Additionally, patients always have the right to report concerns or grievances to the appropriate state medical Board, or other applicable regulatory body. The Practice provides you with information regarding how to contract such regulatory bodies in your “new patient” documents. You may, at any time, request that the Practice provide you with that information again.
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
THE NOTICE OF PRIVACY PRACTICE 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 IT EXPLAINS:
- How the Practice will use and disclose your protected health information.
- Your privacy rights with regard to your protected health information.
- The Practice’s obligations concerning the use and disclosure of your protected health information.
You acknowledge that you have received a copy of the Practice’s HIPAA Notice of Privacy Practices and have been provided an opportunity to review it, and consent to receipt of an electronic copy. You further acknowledge that the Practice’s Notice of Privacy Practices is available from the Practice upon request, and is available at https://www.heal.com/practices/
CONSENT TO EMAIL AND ELECTRONIC COMMUNICATIONS
You consent to the use of unsecured email, mobile phone text message, or other electronic methods of communication (“E-messages”) between yourself and the Practice, your treating provider, and any other agents or representatives of the Practice, for purposes of discussing personal material relevant to your treatment or health records. You understand that E-Messages are typically not confidential means of communication and that there is a reasonable chance that a third-party (including people in your home or other environments who can access your phone, computer, or other devices; your employer, if using your work email; and/or third parties on the Internet such as server administrators and others who monitor Internet traffic) may be able to intercept and see these messages. You have been informed of the risks—including but not limited to the risk with respect to the confidentiality of your treatment—of transmitting your protected health information by an unsecured means. You acknowledge that E-messages are not to be used in the case of an emergency, and that you should call 911 or proceed directly to the nearest emergency room.
CONSENT TO USE OF TELEHEALTH
You acknowledge that you have read, understand and agree to the information below, which applies if you have requested telehealth services, and that your name and identity have been correctly identified in communications with the Practice:
I hereby consent to receiving treatment through telehealth from the Practice as part of my health evaluation and treatment. I further give the Practice and its providers permission to consult with relevant specialists as needed during the course of my treatment, and I further consent to the Practice and its providers forwarding my medical information to my primary care provider/provider of record (if not the Practice) or, upon my request, to any other provider. I am providing the foregoing consents based on my understanding of the following:
- During my treatment through telehealth, my provider and I will be in different physical locations and my medical and/or health information will be communicated to health care providers at those other physical locations. I may benefit from the use of telehealth, including from the increased availability and access to care, but results cannot be guaranteed or assured. Furthermore, the use of telehealth may present certain risks, such as delays in medical evaluation and treatment due to technological issues, the need to reschedule if the transmitted information is of insufficient quality, or failure of potential failure security protocols which could cause disclosure of personal information. In addition, I understand a lack of access to my complete medical record could result in adverse drug interactions or other unintended results, and I understand it is my responsibility to share complete and accurate information with my provider.
- My treating provider’s information, including name, highest level of academic degree, specialty, license status, license number, board certification (where applicable), are available through the HealTM Application, and if my treating provider is a physician assistant or nurse practitioner the name of the delegating/supervising physician is also available. In the event of an adverse reaction to treatment or the inability to communicate as a result of a technological failure, I understand that I may contact my treating provider for further assistance or to schedule follow-up care by calling 844.644.HEAL, emailing Support@Heal.com, or visiting heal.com.
- The Practice may use telehealth to conduct examinations, diagnose and treat medical conditions, interact with me in connection with prescriptions and refills, and otherwise communicate with me about my health. I understand and agree that my provider has the sole responsibility and discretion to determine whether telehealth is appropriate for the diagnosis or treatment of my specific condition(s).
- I have the right to withdraw my consent to the Practice’s use of telehealth at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. Receiving treatment through telehealth does not mean that I cannot receive in-person health care services now or in the future.
- The information and data disclosed by me during the course of my treatment through telehealth may be integrated into my medical record and will generally be protected and confidential. The Practice uses secure technology that complies with federal privacy laws to provide telehealth services, incorporating reasonable and appropriate network and software security protocols to protect patient information and ensure its integrity. Without limiting the foregoing, the Practice uses industry leading security standards to maintain the highest level of security for our patients, including multi-factor authentication and AES256 encryption to protect data. However, I understand and accept that, as is the case with all electronic data, there is a risk that data security protocols could fail or be breached, which may result in the unintended disclosure of my information.
- The Practice will not provide my personally-identifiable information to any third parties without my express consent. Notwithstanding the foregoing, I understand that my healthcare information may be shared with other individuals and entities for the Practice’s scheduling, billing, and other treatment, payment, and health care operations purposes, or other uses or disclosures permitted or required by law, and I consent to such use and disclosure solely to the extent such use or disclosure complies with applicable federal and state privacy laws.
- The Practice and its providers are not responsible for any information lost as a result of any technical failures encountered during the course of my telehealth treatment.
- An in person evaluation is required prior to prescribing any schedule II, III, or IV drugs and at least every 90 days for ongoing prescriptions. However, your doctor – at their discretion – may choose to renew or adjust prescriptions for controlled medications via telehealth as long as you have had an in person visit in the prior 90 days.
- I understand that if I am experiencing a medical emergency I will be directed to call 911, and that the Practice is not able to connect me directly to local emergency services.
- I have discussed the foregoing information with my provider and all of my questions have been answered to my satisfaction.
You acknowledge that you (1) have read, understand and accept the terms of the Practice’s Patient Agreement; (2) have received a copy of the Practice’s Notice of Privacy Practices and further acknowledge that the Practice’s Notice of Privacy Practices is available from the Practice upon request; (3) consent to the use of E-messages between yourself and the Practice, the Practice’s providers, and/or other agents or representatives of the Practice, for purposes of discussing personal material relevant to your treatment or health records; and (4) have read and understand the information contained in the Consent to Use of Telehealth above, and are providing the consents expressly set forth therein.
If patient is unable to consent, you acknowledge that you agree to the terms and conditions of this agreement as the legally authorized representative of patient.