Informed Consent of Services
Delivering telemedicine services involves the use of electronic communications to enable healthcare providers at different locations to share individual patients’ medical information to improve patient care. Providers may include primary care practitioners, specialists, subspecialists, and/or other allied healthcare professionals. The information may be used for diagnosis, therapy, follow-up, and/or education and may include any of the following:
- Patient medical records
- Medical images
- Medical test results
- Live two-way audio and video
- Output data from medical devices and sound and video files.
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data. They will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Responsibility for the patient care should remain with the patient’s local clinician, if you have one, as does the patient’s medical record.
Improved access to medical care by enabling patients to remain in their local healthcare site (i.e., home) while the physician consults and obtains test results at distant/other sites.
More efficient medical evaluation and management.
We are obtaining the expertise of a specialist.
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
In rare cases, the consultant may determine that the transmitted information is of inadequate quality, thus necessitating a face-to-face meeting with the patient or at least a rescheduled video consult.
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
In sporadic instances, security protocols could fail, causing a breach of privacy of personal medical information.
In rare cases, a lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other judgment errors. By checking the box associated with “Informed Consent,” you acknowledge that you understand and agree with the following:
- I understand that the laws that protect the privacy and the confidentiality of medical information also apply to telemedicine and that no information obtained in telemedicine that identifies me will be disclosed to researchers or other entities without my consent.
- I understand that I have the right to withhold or withdraw my consent to the use of telemedicine during my care at any time without affecting my right to future care or treatment.
- I understand the alternatives to telemedicine consultation as they have been explained to me, and in choosing to participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location or a testing facility, at the direction of the consulting healthcare provider.
- I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
- I understand that I may expect the anticipated benefits from telemedicine in my care but that no results can be guaranteed or assured.
- I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my healthcare provider and consulting healthcare provider to operate the video equipment. The people mentioned above will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time.
Patient Consent To The Use of Telemedicine
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction.
I have read this document carefully and understand the risks and benefits of the teleconferencing consultation. I have had my questions regarding the procedure explained, and I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.
By checking the box containing “INFORMED CONSENT FOR TELEMEDICINE SERVICES” I hereby state that I have read, understood, and agree to the terms of this document.
PLEASE READ THESE TERMS OF SERVICE CAREFULLY
These Terms of Service govern your use of the Site only and do not govern your use of other MDVIP365 DBA Priority Medical Group services.
We reserve the right to change these Terms of Service or to impose new conditions on the use of the Site from time to time, in which case we will post the revised Terms of Service on the Site and update the “Last Updated” date to reflect the date of the changes. By continuing to use the Site after we post any such changes, you accept the Terms of Service as modified. We also reserve the right to deny access to the Site or any features of the Site to anyone who violates these Terms of Service or who, in our sole judgment, interferes with the ability of others to enjoy our Site or infringes on the rights of others.
- Services Provided
MDVIP365 DBA Priority Medical Group provides internet healthcare resources to connect individuals with participating physicians, licensed therapists, and other licensed healthcare practitioners (the “Providers”) in real-time, via live video conferencing, telephone and/or secure messaging for the diagnosis and treatment of patients over the Internet, as well as providing other types of administrative services and information (“Services”). All of the participating Providers are independent contractors. Providers may record video conference consultations, and MDVIP365 DBA Priority Medical Group may record telephone calls for quality purposes. MDVIP365 DBA Priority Medical Group provides no medical or Provider services.
- Your Limited Right to Use Site Materials
The Site and all the materials available are the property of MDVIP365 DBA Priority Medical Group and/or our affiliates or licensors. They are protected by copyright, trademark, and other intellectual property laws. The Site is provided solely for your personal, noncommercial use. You may not use the Site or the materials available on the Site in a manner that constitutes an infringement of our rights or that has not been authorized by us. More specifically, unless explicitly authorized in these Terms of Service or by the owner of the materials, you may not modify, copy, reproduce, republish, upload, post, transmit, translate, sell, create derivative works, exploit, or distribute in any manner or medium (including by email or other electronic means) any material from the Site. However, you may download and/or print one copy of individual pages of the Site for your personal, non-commercial use, provided that you keep intact all copyright and other proprietary notices. Information about requesting permission to reproduce or distribute materials from the Site can be obtained by contacting us as follows:
- Our Right to Use Materials You Submit or Post
When you submit or post any material (including any photos or videos) via the Site, you grant us, and anyone authorized by us, a royalty-free, perpetual, irrevocable, non-exclusive, unrestricted, worldwide license to use, copy, modify, transmit, sell, exploit, create derivative works from, distribute, and/or publicly perform or display such material, in whole or in part, in any manner or medium (whether now known or hereafter developed), for any purpose that we choose. The foregoing grant includes the right to exploit any proprietary rights in such posting or submission, including, but not limited to, rights under copyright, trademark, or patent laws that exist in any relevant jurisdiction. Also, in connection with the exercise of these rights, you grant us, and anyone authorized by us, the right to identify you as the author of any of your postings or submissions by name, e-mail address, or screen name as we deem appropriate. You understand that the technical processing and transmission of the Site, including content submitted by you, may involve transmissions over various networks and may involve changes to the content to conform and adapt it to the technical requirements of connecting networks or devices. You will not receive any compensation of any kind for the use of any materials submitted by you.
- Limitations on Linking and Framing
You are free to establish a hypertext link to our Site if the link does not state or imply any sponsorship of your website or service by MDVIP365 DBA Priority Medical Group or MDVIP365 DBA Priority Medical Group.com. However, without our prior written permission, you may not frame or inline link any of the content of our Site or incorporate into another website or other service any of our material, content, or intellectual property.
- Site Registration Process
- Responsibility for Your Username and Password
In order to use certain features of our Site, you may need a username and password, which you will receive and/or create through the Site’s registration process. We reserve the right to reject or terminate the use of any username that we deem in our sole judgment offensive or inappropriate. In addition, we also reserve the right to terminate the use of any username or account or to deny access to the Site or any features of the Site to anyone who violates these Terms of Service or who, in our sole judgment, interferes with the ability of others to enjoy our website or infringes the rights of others. You are responsible for maintaining the confidentiality of your password and account, and you are responsible for all activities (whether by you or by others) that occur under your password or account. You agree to notify us immediately of any unauthorized use of your password or account or any other breach of security and to ensure that you exit from your account at the end of each session. We cannot and will not be liable for any loss or damage arising from your failure to protect your password or account information.
- Responsibility for User-Provided Content
The Site may include a variety of features, such as discussion forums, blogs, photo- and video-sharing pages, e-mail services, and social networking features that allow feedback to us and allow users to interact with each other on the Site or to post content and materials for display on the Site. The Site also may include other features, such as personalized home pages and e-mail services that allow users to communicate with third parties. By accessing and using any such features, you represent and agree: (a) that you have read and agree to abide by our Community Rules as set forth below in Section 8; (b) that you are the owner of any materials you post or submit, or are making your posting or submission with the express consent of the owner of the materials; (c) that you are making your posting or submission with the express consent of anyone pictured in any materials you post or submit, (d) that you are 13 years of age or older; (e) that the materials will not violate the rights of, or cause injury to, any person or entity; and (f) that you will indemnify and hold harmless MDVIP365 DBA Priority Medical Group, our affiliates, and each of our and their respective directors, officers, managers, employees, shareholders, agents, representatives and licensors, from and against any liability of any nature arising out of or related to any content or materials displayed on or submitted via the Site by you or by others using your username and password. You also grant us a license to use the materials you post or submit via such features as described in Sections 2-4 above.
Responsibility for what is posted on discussion forums, blogs, photo- and video-sharing pages, and other areas on the Site through which users can supply information or materials or sent via any e-mail services that are made available via the Site lies with each user. You alone are responsible for the materials you post or send. We do not control the messages, information, or files that you or others may transmit, post, or otherwise provide on or through the Site.
You understand that we are not obligated to monitor any discussion forums, blogs, photo- or video-sharing pages, or other site areas through which users can supply information or materials. However, we always reserve the right, in our sole discretion, to screen content submitted by users and to edit, move, delete, and/or refuse to accept any content that, in our judgment, violates these Terms of Service or is otherwise unacceptable or inappropriate, whether for legal or other reasons.
You acknowledge and agree that we may preserve content and materials submitted by you and may also disclose such content and materials if required to do so by law or if, in our business judgment, such preservation or disclosure is reasonably necessary to: (a) comply with legal process; (b) enforce these Terms of Service; (c) respond to claims that any content or materials submitted by you violate the rights of third parties; or (d) protect the rights, property, or personal safety of our Site, us, our affiliates, our officers, directors, employees, representatives, our licensors, other users, and/or the public.
- Community Rules
The Site may include a variety of features, such as discussion forums, blogs, photo- and video-sharing pages, e-mail services, and social networking features that allow feedback to us and allow users to interact with each other on the Site and to post content and materials for display on the Site. The Site also may include other features, such as personalized home pages and e-mail services that allow users to communicate with third parties. By accessing and using any such features, you represent and agree that you will not:
- Restrict or inhibit any other user from using and enjoying the Site.
- Use the Site to impersonate any person or entity or falsely state or otherwise misrepresent your affiliation with a person or entity.
- Interfere with or disrupt any servers or networks used to provide the Site or its features or disobey any requirements, procedures, policies, or regulations of the networks we use to provide the Site.
- Use the Site to instigate or encourage others to commit illegal activities or cause injury or property damage to any person.
- Gain unauthorized access to the Site, or any account, computer system, or network connected to the Site, by means such as hacking, password mining, or other illicit means.
- Obtain or attempt to obtain any materials or information through any means not intentionally made available through the Site.
- Use the Site to post or transmit any unlawful, threatening, abusive, libelous, defamatory, obscene, vulgar, pornographic, profane, or indecent information of any kind, including without limitation any transmissions constituting or encouraging conduct that would constitute a criminal offense, give rise to civil liability, or otherwise violate any local, state, national or international law.
- Use the Site to post or transmit any information, software, or other material that violates or infringes upon the rights of others, including material that is an invasion of privacy or publicity rights or that is protected by copyright, trademark, or other proprietary right, or derivative works with respect thereto, without first obtaining permission from the owner or rights holder.
- Use the Site to post or transmit any information, software, or other material that contains a virus or other harmful component.
- Use the Site to post, transmit, or in any way exploit any information, software, or other material for commercial purposes or that contains advertising.
- Use the Site to advertise or solicit anyone to buy or sell products or services or to make donations without our express written approval.
- Gather for marketing purposes any e-mail addresses or other personal information that other users of the Site have posted.
- Contact anyone who has asked not to be contacted.
- Engage in personal attacks, harass, or threaten, question the motives behind others’ posts or comments, deliberately inflame or disrupt the conversation, or air personal grievances about other users.
- Repeatedly posting the same or similar content or otherwise imposing an unreasonable or disproportionately large load on our infrastructure.
- Take or cause to be taken any action that disrupts the normal flow of postings and dialogue on our Site (such as submitting an excessive number of messages – i.e., a flooding attack) or that otherwise negatively affects other users’ ability to use the Site and/or services; or
- Use automated means, including spiders, robots, crawlers, data mining tools, or the like to download data from our Site. Exception is made for Internet search engines (e.g., Google) and non-commercial public archives (e.g., archive.org) that comply with our Terms of Service.
We reserve the right to deny access to the Site or any features of the Site to anyone who violates these Community Rules or who, in our sole judgment, interferes with the ability of others to enjoy our website or infringes the rights of others.
- Limitation on Use of Company Directories
The information contained in any company directories that may be provided on the Site is provided for business lookup purposes and is not to be used for marketing or telemarketing applications. This information may not be copied or redistributed and is provided “AS IS” without warranty of any kind. In no event will we or our suppliers be liable in any way for such information.
- Modifications to, or Discontinuations of, the Site
We reserve the right at any time and from time to time to modify or discontinue, temporarily or permanently, the Site or any portion thereof, with or without notice. You agree that we will not be liable to you or any third party for any modification, suspension or discontinuance of the Site or any portion thereof.
Throughout our Site, we may have provided links and pointers to Internet sites maintained by third parties. Our linking to any such third-party sites does not imply an endorsement or sponsorship of such sites, or the information, products or services offered on or through the sites. In addition, neither we nor our parent or subsidiary companies nor any of our respective affiliates operate or control in any respect any information, products, or services that such third parties may provide on or through the Site or on websites linked to by us on the Site.
THE INFORMATION, PRODUCTS AND SERVICES OFFERED ON OR THROUGH THE SITE AND ANY THIRD-PARTY SITES ARE PROVIDED “AS IS” AND WITHOUT WARRANTIES OF ANY KIND EITHER EXPRESS OR IMPLIED. TO THE FULLEST EXTENT PERMISSIBLE PURSUANT TO APPLICABLE LAW, WE DISCLAIM ALL WARRANTIES, EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. WE DO NOT WARRANT THAT THE SITE OR ANY OF ITS FUNCTIONS WILL BE UNINTERRUPTED OR ERROR-FREE, THAT DEFECTS WILL BE CORRECTED, OR THAT ANY PART OF THE SITE, INCLUDING BULLETIN BOARDS OR THE SERVERS THAT MAKE IT AVAILABLE, ARE FREE OF VIRUSES OR OTHER HARMFUL COMPONENTS.
WE DO NOT WARRANT OR MAKE ANY REPRESENTATIONS REGARDING THE USE OR THE RESULTS OF THE USE OF THE SITE OR MATERIALS ON THE SITE OR ON THIRD-PARTY SITES IN TERMS OF THEIR CORRECTNESS, ACCURACY, TIMELINESS, RELIABILITY OR OTHERWISE.
You must provide and are solely responsible for all hardware and/or software necessary to access the Site. You assume the entire cost of and responsibility for any damage to, and all necessary maintenance, repair, or correction of, that hardware and/or software.
The Site is provided for informational purposes only and is not intended for trading, investing, or commercial use. Stock and mutual fund quotes and related financial news stories may be delayed at least 20 minutes, as may be required by the stock exchanges and/or the financial information services. The Site should not be used in any high-risk activities where damage or injury to persons, property, environment, finances, or business may result if an error occurs. You expressly assume all risk for such use.
Your interactions with companies, organizations and/or individuals found on or through our Site, including any purchases, transactions, or other dealings, and any terms, conditions, warranties, or representations associated with such dealings, are solely between you and such companies, organizations and/or individuals. You agree that we will not be responsible or liable for any loss or damage of any sort incurred as the result of any such dealings. You also agree that, if there is a dispute between users of the Site, or between a user and any third party, we are under no obligation to become involved, and you agree to release us and our affiliates from any claims, demands and damages of every kind or nature, known or unknown, suspected and unsuspected, disclosed and undisclosed, arising out of or in any way related to such dispute and/or our Site.
- Limitation of Liability
UNDER NO CIRCUMSTANCES, INCLUDING, BUT NOT LIMITED TO, NEGLIGENCE, WILL WE OR OUR SUBSIDIARIES, PARENT COMPANIES OR AFFILIATES BE LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL OR CONSEQUENTIAL DAMAGES THAT RESULT FROM THE USE OF, OR THE INABILITY TO USE, THE SITE, INCLUDING ITS MATERIALS, PRODUCTS, OR SERVICES, OR THIRD-PARTY MATERIALS, PRODUCTS, OR SERVICES MADE AVAILABLE THROUGH THE SITE, EVEN IF WE ARE ADVISED BEFOREHAND OF THE POSSIBILITY OF SUCH DAMAGES. (BECAUSE SOME STATES DO NOT ALLOW THE EXCLUSION OR LIMITATION OF CERTAIN CATEGORIES OF DAMAGES, THE ABOVE LIMITATION MAY NOT APPLY TO YOU. IN SUCH STATES, OUR LIABILITY AND THE LIABILITY OF OUR SUBSIDIARIES, PARENT COMPANIES AND AFFILIATES, IS LIMITED TO THE FULLEST EXTENT PERMITTED BY SUCH STATE LAW.) YOU SPECIFICALLY ACKNOWLEDGE AND AGREE THAT WE ARE NOT LIABLE FOR ANY DEFAMATORY, OFFENSIVE, OR ILLEGAL CONDUCT OF ANY USER. IF YOU ARE DISSATISFIED WITH THE SITE, OR ANY MATERIALS, PRODUCTS, OR SERVICES ON THE SITE, OR WITH ANY OF THE SITE’S TERMS AND CONDITIONS, YOUR SOLE AND EXCLUSIVE REMEDY IS TO DISCONTINUE USING THE SITE.
You agree to indemnify and hold harmless us, our affiliates, and each of our and their respective directors, officers, managers, employees, shareholders, agents, representatives and licensors, from and against any and all losses, expenses, damages and costs, including reasonable attorneys’ fees, that arise out of your use of the Site, violation of these Terms of Service by you or any other person using your account, or your violation of any rights of another. We reserve the right to take over the exclusive defense of any claim for which we are entitled to indemnification under this section. In such event, you agree to provide us with such cooperation as is reasonably requested by us.
- Suspension and Termination of Access
You agree that, in our sole discretion, we may suspend or terminate your password, account (or any part thereof) or use of the Site, or any part of the Site, and remove and discard any materials that you submit to the Site, at any time, for any reason, without notice. You agree that we will not be liable to you or any third party for any suspension or termination of your password, account or use of the Site or any part thereof, or any removal of any materials that you have submitted to the Site. If we suspend or terminate your access to and/or use of the Site, you will continue to be bound by the Terms of Service that were in effect as of the date of your suspension or termination.
- Notice of Copyright Infringement
If you are a copyright owner who believes your copyrighted material has been reproduced, posted or distributed via the Site in a manner that constitutes copyright infringement, please inform us by e-mail email@example.com Please include the following information in your written notice: (1) a detailed description of the copyrighted work that is allegedly infringed upon; (2) a description of the location of the allegedly infringing material on the Site; (3) your contact information, including your address, telephone number, and, if available, e-mail address; (4) a statement by you indicating that you have a good-faith belief that the allegedly infringing use is not authorized by the copyright owner, its agent, or the law; (5) a statement by you, made under penalty of perjury, affirming that the information in your notice is accurate and that you are authorized to act on the copyright owner’s behalf; and (6) an electronic or physical signature of the copyright owner or someone authorized on the owner’s behalf to assert infringement of copyright and to submit the statement. Please note that the contact information provided in this paragraph is for suspected copyright infringement only. Contact information for other matters is provided elsewhere in these Terms of Service or on the Site.
This agreement is personal to you, and you may not assign it to anyone. If any provision of this agreement is found to be unlawful, void, or for any reason unenforceable, then that provision will be deemed severable from this agreement and will not affect the validity and enforceability of any remaining provisions. These Terms of Service are not intended to benefit any third party and do not create any third-party beneficiaries. Accordingly, these Terms of Service may only be invoked or enforced by you or us. You agree that regardless of any statute or law to the contrary, any claim or cause of action that you may have arising out of or related to use of the Site or these Terms of Service must be filed by you within one year after such claim or cause of action arose or be forever barred.
- Summary Notice of HIPAA Privacy Practices
MDVIP365 DBA Priority Medical Group arranges for the provision of all physician services you may receive through your MDVIP365 DBA Priority Medical Group membership. These physicians and allied healthcare professionals are independent practitioners who advise, diagnose, and prescribe at their own discretion subject to their individual state regulations. MDVIP365 DBA Priority Medical Group does not directly provide or arrange for care, nor does it knowingly maintain any medical information about you for purposes of providing or facilitating care.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY HEALTHNATION AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by MDVIP365 DBA Priority Medical Group in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the Patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.
MDVIP365 DBA Priority Medical Group has prepared this “Summary Notice of HIPAA Privacy Practices” to explain how it is required to maintain the privacy of your health information and how it may use and disclose your health information. A Notice of HIPAA Privacy Practices containing a more complete description of the uses and disclosures of your health information is available to you upon request.
MDVIP365 DBA Priority Medical Group may use and disclose your medical records for each of the following purposes: treatment, payment, and health care operations.
- TREATMENT means providing, coordinating, or managing health care and related services by one or more health care providers.
- PAYMENT means such activities as obtaining payment or reimbursement for services, billing or collection activities and utilization review.
- HEALTH CARE OPERATIONS include managing your Electronic Medical Record to facilitate diagnostic medical consultations with participating physicians, as well as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service.
MDVIP365 DBA Priority Medical Group may also create and distribute de-identified health information by removing all references to individually identifiable information.
MDVIP365 DBA Priority Medical Group may contact you to provide information about our services or other health-related services that may interest you.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, and MDVIP365 DBA Priority Medical Group is required to honor and abide by that written request, except to the extent that it has already taken actions relying on your authorization.
You have the following rights concerning your protected health information, which you can exercise by presenting a written request addressed to the MDVIP365 DBA Priority Medical Group Compliance Officer at the address above.
- You have the right to ask for restrictions on how MDVIP365 DBA Priority Medical Group uses and discloses your health information for treatment, payment, and healthcare operations. You may also request that MDVIP365 DBA Priority Medical Group limit its disclosures to persons assisting your care. MDVIP365 DBA Priority Medical Group will consider your request but is not required to accept it.
- You have the right to request that you receive communications containing your protected health information from MDVIP365 DBA Priority Medical Group by alternative means or at alternative locations. For example, you may ask that MDVIP365 DBA Priority Medical Group only contact you at home or by mail.
- Except under certain circumstances, you have the right to inspect and copy medical, billing, and other records used to make decisions about you. If you request copies of this information, MDVIP365 DBA Priority Medical Group may charge you a nominal fee for copying and mailing.
- If you believe that information in your records needs to be corrected or completed, you can ask us or MDVIP365 DBA Priority Medical Group to update the existing information or add missing information. Under certain circumstances, your request may be denied, such as when the information is accurate and complete.
- You have a right to receive a list of certain instances when MDVIP365 DBA Priority Medical Group has used or disclosed your medical information. You may be charged a fee if you ask for this information from us or MDVIP365 DBA Priority Medical Group more than once every twelve months.
Consent to Obtain Patient Medication History
Patient medication history is a list of healthcare providers’ prescriptions for you. Various sources, including pharmacies and health insurers, contribute to this history collection.
The collected information is stored in the practice’s electronic medical record system and becomes part of your personal medical record. Medication history is significant in helping providers treat your symptoms and/or illness properly and avoid potentially dangerous drug interactions.
It is very important that you and your provider discuss all your medications to ensure that your recorded medication history is 100% accurate. Some pharmacies need to make prescription history information available, and your medication history might not include drugs purchased without using your health insurance.
Also, over‐the‐counter drugs, supplements, or herbal remedies you take alone may not be included.
Patient Consent for Use and Disclosure
of Protected Health Information
I consent to use and disclose my protected health information (PHI) to perform treatment, payment, and health care operations (TPO).
With this consent, the Practice may and/or call me, text, or email me at my home or other alternative location and leave a message and/or by voice, text, email, or in person about any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and anything of my clinical care, including laboratory test results.
With this consent, the Practice may mail to my home or other alternative location any items that assist the practice in performing TPO, such as appointment reminder cards, patient statements, and anything pertaining to my clinical care if they are marked “Personal and Confidential.”
- Thank you for choosing us for your healthcare needs. Our goal is to provide and maintain a good physician-patient relationship. The following is our Financial Policy, which we ask you to review and sign before your first visit.
- General Information: Your co-payment, deductible, co-insurance, or pending balance is due at the time of service. We accept cash, , American Express, Discover, MasterCard, and Visa. We can also store your preferred method of payment in your account demographics.
- Regarding Insurance: Our providers participate in various insurances and managed care plans. We are happy to bill your health insurance carrier as a courtesy to you. We suggest all patients review their health coverage with their carrier before receiving services or treatment. The patient is responsible for notifying us of any changes regarding the insurance policy. Your insurance policy is a contract between you and your insurance company, and the staff will only know some of the terms of your insurance policy. Please be aware that some, and perhaps all, of the services provided may be non-covered and not considered reasonable and necessary under the Medicare program and/or other medical insurance. The patient/financial guardian will be responsible for any remaining balances.
- Self-Pay Patients: Patients without health insurance are expected to pay at the time of service. We offer a 20% discount on most services rendered as a courtesy. If you cannot pay the entire balance at the time of service, the remaining balance is expected upon receipt of your first statement.
- Payment Arrangements: Priority Medical Group has a plan for outstanding balances owed under certain circumstances of financial hardship. We are willing to discuss your situation and try to work out a plan that will meet both your needs and the needs of the medical group. Please consult with one of our billing staff for further information.
- Worker’s Compensation: We will bill your employer’s workers’ compensation insurance carrier and follow all other procedures as required by the state’s worker’s compensation laws. As the patient, it is your responsibility to notify us before the visit that it is a work-related case and to provide us with the appropriate worker’s compensation policy information.
- Automobile/Other Liability Cases: Due to state laws surrounding auto insurance payments and payment delays, we regret to inform you that we may not be able to bill third party administrators in liability cases. In addition, we cannot suspend our normal billing and collection process when services have been rendered. Your health insurance carrier or financial guarantor will be billed for the services.
- Returned EFTs and Insufficient Funds Notice (including Credit Card Chargebacks (CCC)): There will be a $60.00 fee on all returned EFT/CCC. If an EFT/CCC is returned for insufficient funds, we reserve the right to contact your bank to verify funds for any future EFT/CCC presented for payment on your account.
- Additional Forms: Any outside forms incur an additional $35 charge that must be paid before the form can be filled out. These forms will be available for pickup 48 hours after presentation to the provider.
- No-Show Appointments: Unless cancelled 24hrs. Before the scheduled appointment, your appointment will be considered a no-show. Our policy allows us to charge a $100.00 fee for these missed appointments. Please help us serve you better by keeping your scheduled appointments. You will be rescheduled for future appointments once your account balance is paid in full.
- ADDITIONAL PAPERWORK FMLA, LETTER OF MEDICAL NECESSITY, WORK ACCOMIDATION, AND ANY ADDITIONAL FORMS THAT REQUIRE THE LICENSED PROVIDER ADDITIONAL TIME GREATER THAN 10 MINUTES WILL INCUR AN ADDITIONAL COST, AS THIS IS NOT REIMBURSED BY INSURANCE AND IS CONSIDERED AN ADMINISTRATIVE TASK. YOU WILL BE NOTIFIED AND SIGN A PATIENT-SPECIFIC NOTICE IF THIS IS REQUIRED.
CONTROLLED SUBSTANCE-SPECIFIC CONSENTS
Overview of Opioid Treatment Program Regulations by State
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Evidence-Based Practice Guidelines
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All CONTROLED SUBSTANCES REQUIRE A FACE-FACE ID VERICATION WITH STATE FEDERAL ISSUED ID USING an ASYCHRONOUS CONTINIOUS VIDEO VISIT EACH AND EVERY ENCOUNTER. I UNDERSTAND THE COVID-19 TEMEDACINE RULES HAVE BEEN EXTENDED THROUGH NOVEMBER 1ST, 2024.
I UNDERSTAND AND AGREE THAT ONGOING AND EVERCHANGING FEDERAL AND SPECIFIC STATE GUIDELINES MAY BE REQUIRED AT ANY TIME, AND UPDATES TO THESE CHANGES ARE FULLY ACKNOWLEDGED AND BINDING AT ANY TIME AND I IMPLICITLY AGREE AND INDEMNIFY MDVIP365 LLC DBA PRIORITY MEDICAL GROUP FROM ANY AND ALL LIABILITY RELATED TO THE ADDITIONAL PATIENT CONSENTS
I FURTHER UNDERSTAND AND AGREE TO ALL SPECIFIC PATIENT AGREEMENTS BELOW BY CHECKING THE I AGREE BOX DURING EACH VIDEO VISIT.
Opioid Treatment Informed Consent
Potential Risks, adverse reactions, complications, and medication interactions associated with opioids, including death (but are not limited to the following): allergic reactions, slowing of breathing rate, slowing of reflexes or reaction time, sleepiness, dizziness and/or confusion, impaired judgment and inability to operate machines or drive motor vehicles, nausea, vomiting and/or constipation, itching, physical dependence or tolerance to pain relieving properties of the medication, addiction, changes in sexual function, changes in hormonal levels.
- If a benzodiazepine is taken with an opiate, there is an increased chance of slowing the breathing rate, sleepiness, dizziness, confusion, and impaired judgment.
- Use of opiates poses a special risk to women who are pregnant or who may become pregnant. If I plan on becoming pregnant or believe that I have become pregnant while taking this pain medicine, I will immediately call my obstetrician and this office to inform them.
The following alternatives to prescribed opioids have been explained to me, and I have freely consented to taking opioid medication (check all that apply):
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
- [Serotonin and Norepinephrine Reuptake Inhibitors
- Neuro stimulators
- [Physical Therapy
- [Massage, Acupuncture, Chiropractic Care
- Injections (Nerve, trigger point, Radiofrequency, or epidural injections)
Monitoring for effectiveness will occur with this medication if used for more than 30 calendar days, as indicated per the prescriber’s clinical discernment, medical necessity, and evidenced-based practice and regulations of the Drug Enforcement Agency and Federal/state guidelines and applicable laws.
TREATMENT AGREEMENT FOR STIMULANT MEDICATIONS (ADHD Medication)
Stimulant medications are federally controlled substances because they can be abused or lead to dependence or withdrawal. Our department provider would like to inform you that the new Senate Bill, SB482, requires regularly checking the national database for other sources of prescriptions. The clinic’s policy is to check a urine drug screen before starting medication for new patients or new prescriptions. We may also check urine drug screens on a random basis. It is the clinic policy to prescribe no more than a 3-month supply. The provider must approve refills for each request. When you are three days away from being out, please call the pharmacy number on the prescription bottle or generate a request online via kp.org. Stimulant prescription will only be released if you agree to this treatment contract. If you are in the office, you are expected to sign the contract or receive this message via secure message (email). Please respond with your agreement. If we proceed with stimulant treatment and no response is received within 30 days, it will be assumed that you accept the terms of the treatment agreement.
By consenting to start this medication, you are agreeing to the following:
This consent is all-encompassing for all patients across the lifespan this includes Geriatric patients (age 65 to 120 years of age), adults (age 18 – 64 years old), Pediatrics ( age 4 to age 12) & Adolescents( age 13 to 17 years of age) that patients (or their guardians) receiving prescriptions for controlled substances be required to sign a Controlled Substance Agreement. By signing this agreement, I agree, or I agree to the following:
- I agree that the patient will take the medication ONLY as prescribed, and the dose will NOT be changed without getting approval from my physician or provider.
- I agree not to share, sell, or otherwise dispense this medication to anyone else.
- I agree not to seek ADHD medicine from any other source, including other physicians, emergency departments, or clinics.
- I understand this medication has potential side effects including but not limited to appetite suppression, headaches, stomach pain, irritability or other temporary behavior changes, and difficulty sleeping. These are less if the medications are prescribed to me in a controlled setting under close monitoring by my doctor or provider.
- I understand that after initiation of treatment, a follow-up visit is required within 30 days, and then every 3 months after that. There are no exceptions to this rule. No refill of the medication prescribed for ADHD can be made if these follow-up visits are not kept.
- Medication refills are authorized once every thirty days if the required follow-up office visits are kept. I will not be provided a refill prescription before these thirty days. Refill prescriptions cannot be mailed, faxed, or called into the pharmacy. The prescription must be picked up at the office by the patient or another person for whom written consent is in the file.
- I understand that to obtain a refill, I must call the clinic Monday-Friday 8:00 am to 4:30 pm the day before the refill expires, to request a refill to be picked up the next day the office is open. It is important to ensure the patient has enough medication to get through weekends, holidays, or after hours because the provider on call will not refill these prescriptions.
- I will notify the provider if he or she is being prescribed other controlled substances (i.e. opioids, benzodiazepines, sedatives, etc.), including those prescribed by non-Kaiser providers. It will be up to the provider whether stimulants may be prescribed concurrently with these medications, or the dose may be changed due to the risk of adverse side effects.
- Lost or destroyed medication may be replaced only once. Provider may replace stolen medication if I can present a police report of the theft, and this will only be done once. For any further losses, the stimulant may be tapered and discontinued.
- I will not use illegal drugs. If illegal drug use is suspected, the provider will stop prescribing the medication.
- I consent to the cannabis policy.
- I consent to periodic random urine samples for drug testing. If the urine drug screen is not obtained in the time frame requested by the provider, the provider will stop prescribing the stimulant.
- I permit the provider to coordinate care with the primary care physician and other specialists involved in his or her care.
- I will not obtain stimulants from other sources. If there are multiple sources of stimulants, the provider will stop prescribing the stimulant.
- I know that this medication is given to help control the effects of ADHD. It is not a cure. The effectiveness of the treatment determines the duration of use.
- I understand this medication is potentially addictive, and the chances of addiction are less if the medications are prescribed to me in a controlled setting under close monitoring by my doctor or provider. This requires regular office visits and or telemedicine visits to follow my progress.
- I agree that this medication will be stopped if my ability to function does not improve, if the medication loses its effectiveness if I do not attend required office appointments, or if there is reason to believe I am misusing the medication in any way.
- I have had the risks associated with taking this medication explained to me and have decided that the benefits outweigh the risks.
- If I am unable to take the medication due to allergic or otherwise adverse reaction, I will notify the prescriber and discard the remainder.
- I understand that if any of this medication needs to be discarded, I contact my local police department to locate a drug disposal location.
- I authorize Priority Medical Group to review medication information with other doctors, hospitals, and pharmacists; additionally, to contact any groups and organizations involved with my care and involved with the investigation of medication and drug abuse. I give permission to my provider to discuss my care with past caregivers, all pharmacies, and policing agencies.
Benzodiazepine Therapy Agreement & Consent
This document is an agreement between patient and physician regarding the use of benzodiazepines, a class of medications that are used to treat a variety of conditions, including anxiety, insomnia, muscle spasticity, convulsive disorders, as well as detoxification from alcohol and other substances. This document establishes clear guidelines for the safe use of these medications.
THE TELEMEDICINE USER receiving benzodiazepine medication) has agreed to use this medication as part of my treatment.
My provider is prescribing this medication to me for a diagnosis of: Anxiety and/or other medically necessary treatment for my conditions.
I understand that the purpose of this medication is to treat the diagnosis listed above and ultimately improve my quality of life. Alternative therapies have been explained and offered, including the possible risks and benefits of other types of treatments that do not involve the use of benzodiazepines.
l am aware that use of benzodiazepines has certain associated risks including but not limited to:
- poor concentration/confusion
- impaired coordination
- stomach upset
- muscle weakness
- blurred vision
- memory loss
- subtle personality changes
- psychological addiction
I will not be involved in any activity that may be dangerous to me or someone else while taking this medication. I am aware that benzodiazepines use slows reflexes and reaction time, increasing the risk of motor vehicle accidents. Activities that could be dangerous include, but are not limited to, operating heavy equipment or motor vehicles, working in dangerous environments or being responsible for another individual who is unable to care for themselves.
I am aware that tolerance can occur with the use of benzodiazepines. Tolerance is defined as a need for a higher dose to maintain the same effect. Suppose my treating physician determines that continued escalation of the dose is not in my best interest. In that case, the benzodiazepine may need to be tapered and discontinued and may necessitate another form of treatment.
I understand that physical dependence is possible within a few weeks of starting benzodiazepine therapy. I am aware that physical dependence means that if my benzodiazepine use is markedly decreased, stopped or reversed, I could experience a withdrawal syndrome (including but not limited to sweating, increased heart rate and high blood pressure, insomnia, abdominal cramps, tremors, diarrhea, muscle or bone aches, seizures), which may occur in 24- 48 hours of last dose. Withdrawal symptoms are usually self-limited but could, in rare cases, be life-threatening and may require hospitalization.
I understand that psychological addiction is a possible risk to the use of benzodiazepines. Addiction is recognized when an individual abuses a drug to obtain mental numbness or euphoria; when an individual shows a drug craving behavior, visits multiple doctors and pharmacies in pursuit of a medication or shows a manipulative attitude towards the provider in order to obtain the drug. Addictive behavior is the reason for the drug to be tapered and discontinued.
[checkbox] Females only: I understand that while on benzodiazepine therapy, I should maintain safe and effective birth control. If I plan to become pregnant or believe that I am pregnant while taking this medication, I will immediately notify my provider. I am aware that benzodiazepines cross the placenta, can cause birth defects, and are therefore classified as class D teratogens. They may lead to the development of dependence and consequent withdrawal symptoms in the fetus. Benzodiazepines are excreted in
breast milk and are usually contraindicated in breastfeeding mothers.
All controlled substances must come from the provider whose signature appears below or, during his or her absence, by the covering provider unless specific authorization is obtained for an exception. I will tell my provider about all other medicines and treatments I receive.
Because these drugs have the potential for abuse, strict accountability is necessary when use is prolonged. I understand the importance of compliance to the rules outlined in this agreement to protect my access to controlled substances and to protect my provider’s ability to prescribe to me.
Rules of Benzodiazepine Therapy Agreement
l understand that I have the following responsibilities:
- I will take medication as prescribed by my provider. I will communicate fully with my provider about the character and intensity of my symptoms, the effect on my daily life, and how well the medicine is helping to relieve them.
- I will not increase or change how I take my medications without consultation with my provider during scheduled appointments (not via phone, at night, on weekends or holidays).
- I will only ask for refills at the prescribed interval. Lost or misplaced prescriptions will not be replaced.
- I will keep my medications and prescriptions in a secure, safe place (preventing others access to these medications).
- If my medication has been stolen, a copy of the police report must be given to my provider for replacement to be considered.
- Timely requests (two business days) for refills are my responsibility. Refills of my prescriptions for benzodiazepines will be made only at the time of an office visit or during regular office hours. No refills will be available during evenings or on weekends. In accordance with state law, prescriptions must be ordered by my provider electronically (e-prescribed) and will not be mailed.
- I will not place calls to the office staff with demands for variations or exceptions to the contract.
- I will not be disrespectful, use profanity, or harass the office staff and understand that doing so could be grounds for discharge from PMG.
- I will not share my medication with anyone.
- Renewals are contingent upon me keeping scheduled appointments and following prescription directions. I understand that my prescribing provider will want to review my benzodiazepine prescription with me at least annually during an office visit.
- I understand that my provider will verify that I am receiving only the controlled substances that I have reported previously and only from prescribers that have been previously reported by checking the Arizona Prescription Monitoring Program website as required by law.
- I understand that I can only fill prescriptions at a pharmacy located in the state of Arizona.
- I will not request benzodiazepines or controlled substances from other providers, including any Emergency Room (ER) without also notifying my prescribing provider at PMG. I understand that other providers should not change the dose of my benzodiazepine and I will notify my provider of any changes to my medications made by another provider and the reason for the change.
- I will inform my other healthcare providers, including ER providers, that I am taking these benzodiazepines and that I have signed a benzodiazepine contract with the physician listed below.
- l will inform my provider of all other medications I am taking, to include over the counter, herbal, and prescribed medicines.
- I will inform my provider of any new medications or medical conditions, including ER treatment or pregnancy.
- I will participate in any medical, psychological, or psychiatric assessments or treatment programs designed to improve the safety and benefit of the benzodiazepine treatment plan as recommended by my provider.
- Should my provider deem it appropriate, I consent to random blood or urine drug screenings to ensure that I am taking only prescribed drugs. I understand that all out-of-pocket expenses associated with drug screenings will be my responsibility.
- I consent to random pill counts. If requested, I will bring my medication, in the original container, to PMG at the requested time so that the clinical staff may verify the number of pills.
- I agree to waive any applicable privilege or right to privacy or confidentiality concerning the prescribing of my medications and authorize my providers, pharmacy, and insurers to cooperate fully with any city, state, or federal law enforcement agency in the investigation of any possible misuse, sale, or other diversion/inappropriate use of my benzodiazepines.
- l will not use street drugs or another person’s prescriptions. I will not use alcohol while taking this medication. I will inform my provider of alcohol or drug use, past or present, as well as any history of alcoholism or addiction. My use of this medication will be limited to times when I am not driving or operating machinery and shall be used in a manner consistent with my provider’s recommendations.
- I authorize my provider to provide a copy of this agreement to my pharmacy, other healthcare providers,
insurance carrier and any emergency room upon request. I give my permission to allow sharing of my medical history regarding medication use with other healthcare agencies/facilities.
- I understand that my provider may STOP prescribing my benzodiazepine if:
- I do not show any symptom improvement.
- I develop rapid tolerance to the benzodiazepine or if there is a loss of effectiveness from the treatment.
- I develop significant side effects from the medication.
- l refuse to consent to a drug screening, or I am found to be using illegal substances (e.g., Cocaine) or controlled medications prescribed by another provider.
- I fail to comply with all aspects of my treatment program as recommended by my provider, including but not limited to physical therapy, occupational therapy, and counseling.
- I do not fulfill any of the responsibilities outlined above, which may also result in being discharged from care by my provider.
- I miss two consecutively scheduled appointments with my provider.
- I will participate in monthly groups at PMG if my medication is prescribed for any psychiatric reason.
- If my provider determines, for any other reason, that the benzodiazepine treatment is not advisable.
- I understand that my treatment plan and my compliance to this agreement may be reviewed annually or sooner if so indicated by my provider and that I will participate fully and honestly with such a review and reactivation of the agreement/consent.
I have had an opportunity to read the above agreement and consent or have had it read to me. I have had my questions answered to my satisfaction. I understand and accept the risks, conditions, and terms of the proposed treatment as presented. And I have full right and power to be bound by this agreement.
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