Last updated: May 6, 2020
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CONSENT TO TREAT: You acknowledge and agree that you have requested to receive health care treatment and services from medical practices affiliated with Get Heal, Inc., including Dua Medical Inc. d/b/a Heal Doctors, Dua Medical NJ, P.C. d/b/a Heal Doctors, and other medical practices with which Get Heal, Inc. may contract in the future (collectively, “Practice”) and you consent to the rendering of health care treatment and services as considered necessary and appropriate by one of the Practice’s clinicians at the time of the visit. You have the right to decline treatment and services at any time during the course of the visit 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 clinicians concerning the outcome and/or results of any health care treatment or services.
SERVICES: The Practice provides non-emergent, mobile health care services at locations designated by its patients, and health care services delivered via telehealth, including psychological counseling services. The Practice’s services include, general, primary-care services for its adult and pediatric patients, including vaccinations, wellness exams, annual physicals, etc., as well as short-notice, non-emergency, sick-care services for illnesses (such as colds, flu, stomach aches or ear infections) or minor injuries and mental health counseling services. Please note, the Practice does not provide some general obstetrics or gynecological services.
THE PRACTICE DOES NOT PROVIDE EMERGENCY HEALTH CARE: If you have an emergency, such as chest pain, severe shortness of breath, severe headache or bleeding, or a behavioral health emergency, call 911 or proceed directly to the nearest hospital emergency room.
Under certain limited circumstances, a Practice clinician may determine, in his or her best judgment, that he or she is unable to provide health care treatment and services to you, based on information received or conduct occurring during the course of a visit; provided, however, that in no case shall a Practice clinician make such a determination based on a patient’s sex, sexual orientation, race, creed, color, national origin or disability. If a Practice clinician determines he or she is unable to provide health care services after payment is made, the Practice may refund all or a portion of the payment made, in its reasonable discretion.
PRESCRIPTION POLICY: The Practice does not prescribe any narcotics, pain medications, or any other drugs designated as a Schedule I or II drug by the United States Drug Enforcement Administration.
PEDIATRIC VACCINATION POLICY: The Practice strictly follows the vaccination schedules put out by the American Academy of Pediatrics (AAP) and Centers for Disease Control (CDC). The Practice does not accept pediatric patients who are not adequately vaccinated in compliance with these standards. Prior to a child’s visit with the Practice, parents may be required to provide 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 agree to treat the child only if the parents agree to commit to a formal vaccination plan with the Practice that will bring the child’s immunizations in compliance with these schedules. The Practice is committed to doing everything we can to help you understand that vaccinating according to our schedule is the safest thing for your child and our community.
For those families who are not willing to commit to vaccinating their children, parents should schedule an appointment with the child’s primary care provider and/or seek health care services from another health care provider who shares more similar beliefs with the family.
If a Practice clinician arrives at a visit and subsequently learns that the patient’s immunizations are not in compliance with these vaccination standards, or that the parent will not agree to a vaccination plan, then the Practice may charge a non-refundable $99 cancelation fee.
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 health care conditions or potential abnormalities detected or not detected by the visit, and to obtain an appropriate examination by your primary care provider related to the findings, or lack of findings, of this visit.
PATIENT RELATIONSHIP: A patient relationship with the Practice or a Practice clinician is not established until you have actually been seen by a Practice clinician in-person or via telehealth. To facilitate visit bookings and communications with its patients, the Practice licenses access to a proprietary mobile- and web- based application (collectively the “Heal Application”) that is owned by an independent third-party, Get Heal, Inc. The Heal Application allows you to transmit a request for services to the Practice and provides the capability for the Practice to respond and schedule the services. The use of the Heal Application alone does not create any patient relationship with the Practice or any of its clinicians.
Get Heal, Inc. does not provide any health care services. In addition, you acknowledge and agree that you have selected to receive services from the Practice and that no third-party, including Get Heal, Inc., 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 health care. As such, to the extent practicable and/or required by law, the Practice aligns with the standards set forth 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. The Practice does not have any medical office open to the public or any other public facility where the Practice provides health care 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 health care 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 certain 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 Heal Application. When necessary to accommodate patients with disabilities, the Practice may accommodate payment telephonically. The Practice does accept cash payments from patients but does not accept any in-person 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. YOU ACKNOWLEDGE THAT YOU ARE NOT A MEDICAID BENEFICIARY.
Please be aware that some – and perhaps all – of the services you receive may be noncovered 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 to 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 Heal Application with other third-party platforms and/or products that will share your information with the Heal Application. The Practice will be able to see any of your records and data that are shared with the Heal 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, you 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, you 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 of the Practice’s clinicians are appropriately licensed, certified or otherwise permitted to provide applicable health care services in the state where such health care services are provided to you. Your treating clinician’s information, including name, highest level of academic degree, specialty, license status, license number, and board certification (where applicable) are available through the Heal 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 licensing board, or other applicable regulatory body. The Practice provides you with information regarding how to contact 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 PRACTICES 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, a Practice clinician, and any other Practice agents, for purposes of discussing personal material relevant to your treatment or health records. You understand that E-Messages are typically not a 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.
DISCLOSURE OF PHYSICIAN INFORMATION (FOR CALIFORNIA ONLY)
To the extent that you received treatment from a Practice physician, you acknowledge that you have received information regarding the Practice physician’s name and license number, license status, highest level of academic degree, and board certification. The Practice physician is licensed to practice medicine in the state of California and may be a board-certified or board-eligible physician, or a licensed physician in his/her final year of residency who is not yet board-certified or board-eligible. You understand that you can contact the Medical Board of California at the below-listed telephone number and website should you have any questions or concerns.
Medical doctors are licensed and regulated by the Medical Board of California.
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 for yourself or on behalf of a minor patient to the extent that you are authorized to request care on such minor’s behalf, and that the patient’s name and identity have been correctly identified in communications with the Practice:
I 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 health care 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 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 health care 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 health care 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 Heal 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 health care 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 health care 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 health care 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 or damages I incur 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 III, IV or V drugs and at least every 90 days for ongoing prescriptions. However, my doctor – at their discretion – may choose to renew or adjust prescriptions for controlled medications via telehealth, as long as I 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.