Consent to Provision of Telemedicine Services, Acknowledgement of Disclosure of Health Information

 SECTION I – CONSENT FOR TELEMEDICINE SERVICES

1. I agree to participate in a telemedicine (videoconferencing) service with a healthcare provider consulting with me remotely from SAH Telemedicine PC (the “Telemedicine Provider”).
2. I understand that this service is not the same as a direct patient/healthcare provider visit, because I will not be in the same room as the Telemedicine Provider.
3. I understand there are potential risks of the Telemedicine Consultation, including risks attendant to the video conferencing technology such as interruptions due to technical difficulties and unauthorized access by third parties. I understand that my Telemedicine Provider or I can discontinue the Telemedicine Consultation if it is felt that the video conferencing connections or the problem(s) which I may present with are not adequate for the situation.
4. I am choosing to participate in Telemedicine Consultations. I understand that the Telemedicine Consultation will be audio or video recorded for billing, auditing, quality improvement, and related purposes. I understand that these recordings may be maintained with my Protected Health Information (“PHI”), and may be shared as further described in this Consent.
5. I understand that, in an emergent Telemedicine Consultation it is the responsibility of the Telemedicine Provider to advise my primary care provider and relevant caregiver(s) regarding any necessary emergent treatment that I may require as follow-up to my Telemedicine Consultation. I further understand that the Telemedicine Provider’s responsibility to me will conclude upon termination of the Telemedicine Consultation.
6. I give consent to the Telemedicine Provider, its staff, physicians and other practitioners to provide, order and perform such medical care, tests, procedures, and other services that are deemed necessary or beneficial by the Telemedicine Provider for my health and well-being.

SECTION II - CONSENT FOR USE AND RELEASE OF HEALTH INFORMATION

1. I understand that the Telemedicine Provider may request, use and maintain my health information, which may include diagnoses, medications, problems, allergies and other pertinent health information about me in order to provide the Telemedicine Consultation. This health information may originate from, but not be limited to, my primary care provider or a senior living facility, or may be communicated by me during the Telemedicine Consultation, or may be obtained from other sources such as pharmacies, hospitals, labs, healthcare vendors and other healthcare professionals.
2. I understand and agree that the Telemedicine Provider may use and release (disclose) my
   health information, including my Protected Health Information, for treatment, payment and health care operations purposes. This includes, but is not limited to, necessary information to: provide me with or refer me for treatment, seek payment for such treatment, and operate our practice, such as to perform quality improvement and assessment activities, data analytics and similar health care operations activities. I understand and agree that the Telemedicine Provider may also make such uses and disclosures of my health information as further described in the Telemedicine Provider’s HIPAA Notice of Privacy Practices, such as for public health, health care oversight or law enforcement purposes to the extent permitted or required by HIPAA and applicable law.
3. I understand and agree that the individuals and entities to whom Telemedicine Provider may release (disclose) my health information for the above purposes include, but are not limited to:
   1. my primary care provider and any requesting health care provider for my further diagnosis, care or treatment or for that provider’s payment or health care operation purposes;
   2. any person or entity which may be responsible for billing/collection of claims for medical services or products provided to me, including Telemedicine Provider’s management services company and related vendors who provide services to Telemedicine Provider;
   3. any person or entity which is, or may be liable to the Telemedicine Provider or me for all or part of the Telemedicine Provider’s charges, including but not limited to, my insurance companies, HMO or third party payors;
   4. any government agency or other organization responsible for oversight of the Telemedicine Provider or a third party payor;
   5. such other individuals or entities who may be permitted or required by applicable law to receive such health information and as further described in the HIPAA Notice of Privacy Practices. I understand that Telemedicine Provider may also de-identify (anonymize so that my identity cannot be determined) my health information, or engage a third party to de-identify my health information on its behalf, for data analytics, research and other purposes, to the extent permitted by and in accordance with HIPAA and applicable laws, and that such information is no longer subject to this consent after it has been so de-identified.
4. I understand that the Telemedicine Provider may communicate information with me through text or email, and through the Telemedicine Provider’s electronic health record vendor. I hereby consent to receiving such communications through the email address, cell phone, and other telephone numbers I provided to Telemedicine Provider, including via automated dials and text messages, prerecorded messages, and similar forms of communications. I understand this may include appointment reminders, requests to complete surveys or provide feedback, and similar health care related messages, as well as for payment and debt collection purposes.

SECTION III - FINANCIAL CONSENT

1. I authorize payment to the Telemedicine Provider of all monies and/or benefits to which I may be entitled from government agencies, insurance carriers or others who are financially liable for my medical care and treatment to cover the costs of care and treatment. I hereby authorize the release of any/all of my medical records for the purposes of payment of the services rendered to me.
2. I certify that the information given by me in applying for payment under Medicare is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration and/or Centers for Medicare and Medicaid Services, or its intermediaries or carriers, any information needed for this or a related Medicare claim. I request that the payment or authorized benefits be made to me or on my behalf to the Telemedicine Provider for services provided by the Telemedicine Provider.
3. I understand that my Telemedicine Provider will bill my insurance for the Telemedicine Consultation and will bill me personally for any deductible, co-payment, or outstanding balance associated with the Telemedicine Consultation. I acknowledge I may also be billed fees associated with canceling/missing an appointment, visit, or service with a health professional.
4. I understand that there will be a bill even if the Telemedicine Consultation is terminated prior to completion. This may occur if problems with the videoconferencing connection make the Telemedicine Consultation unworkable or if it is determined that my medical issues cannot be adequately addressed in the Telemedicine Consultation.

About the Patient

Signature

I have read and fully understand the above Consent to Provision of Telemedicine Services and Acknowledgement of Disclosure of Health Information, and I voluntarily sign.