ACKNOWLEDGEMENT OF PRIVACY PRACTICES AND PATIENT RIGHTS AND RESPONSIBILITIES
Ascension and its affiliates, including AMG, include a network of health care providers in multiple states. The Notice of Privacy Practices provides information about how protected health information about me (the patient) – may be used and disclosed by my health care provider. I understand that the terms of the Notice of Privacy Practices may change and that I may obtain a current copy of applicable Notice of Privacy Practices in the state in which I am located by accessing the following website: https://healthcare.ascension.org/NPP or by contacting the Privacy Officer listed in the applicable Notice of Privacy Practices. I acknowledge that I have been provided the appropriate Notice of Privacy Practices. I acknowledge that a summary of the telehealth services I receive will be provided to the applicable Ascension or AMG entity providing services to me and that I may download a copy of my summary at any time from Ascension Online Services.
II. IMPORTANT INFORMATION ABOUT YOUR USE OF THE SERVICES
DO NOT USE THE SERVICES FOR EMERGENCY MEDICAL NEEDS. IF YOU EXPERIENCE A MEDICAL EMERGENCY, CALL 9-1-1 IMMEDIATELY.
Operator does not provide any physicians’ or other healthcare providers’ (collectively, “Providers”) services itself. All of the Providers are independent of Operator and merely using the Services to communicate with you. Any information or advice received from a Provider comes from the Provider, and not from Operator. Your interactions with the Providers via the Services are not intended to take the place of your relationship(s) with your regular health care practitioner(s).
NEITHER OPERATOR NOR ANY OF ITS LICENSORS OR SUPPLIERS OR ANY THIRD PARTIES WHO PROMOTE THE SERVICES OR PROVIDE YOU WITH A LINK TO THE SERVICES SHALL BE LIABLE FOR ANY PROFESSIONAL ADVICE YOU OBTAIN FROM A PROVIDER VIA THE SERVICE NOR FOR ANY INFORMATION OBTAINED FROM OUR SERVICES. YOU ACKNOWLEDGE YOUR RELIANCE ON ANY PROVIDERS OR INFORMATION PROVIDED BY THE SERVICES IS SOLELY AT YOUR OWN RISK AND YOU ASSUME FULL RESPONSIBILITY FOR ALL RISK ASSOCIATED THEREWITH.
Operator does not make any representations or warranties about the training or skill of any Providers using the Services. You are ultimately responsible for choosing your particular Provider on the Services. You hereby certify that you are physically located in the State you have entered as your current location on the Services. You acknowledge that your ability to access and use the Services is conditioned upon the truthfulness of this certification and that the Providers you access through the Services are relying upon this certification in order to interact with you. IN
THE EVENT THAT YOUR CERTIFICATION IS INACCURATE, YOU AGREE TO INDEMNIFY OPERATOR AND THE PROVIDERS YOU INTERACT WITH FROM ANY RESULTING DAMAGES, COSTS, OR CLAIMS.
Providers may not utilize the Services to provide fee for service consultations to Medicare or Medicaid beneficiaries. In select circumstances, Providers may utilize the Services to provide consultations to participants in a Medicare Advantage or Managed Medicaid plan. If you provide false or deceptive information regarding your Medicare or Medicaid enrollment status, Operator reserves the right to terminate all current or future use of the Services by you.
III. ACCOUNT ENROLLMENT
To access Providers using the Services, you must first establish an individual user account (“Account”) by providing certain information. You agree that you will not create more than one Account, or create an Account for anyone other than yourself (with the exception of subaccounts established for minor children of whom you are a parent or legal guardian). You agree to provide true, accurate, current, and complete information on the Account enrollment form and to keep this information current and updated as needed.
IV. PROHIBITED CONDUCT
You may not access or use, or attempt to access or use, the Services to take any action that could harm us or any third party, interfere with the operation of the Services, or use the Services in a manner that violates any laws. For example, and without limitation, you may not:
- transmit any message or information under a false name or otherwise misrepresent your affiliation or the origin of materials you transmit;
- provide information on the enrollment form that is untrue, inaccurate, not current, or incomplete;
- transmit any message or information that is unlawful, libelous, defamatory, obscene, fraudulent, predatory of minors, harassing, threatening, or hateful;
- transmit any message or information that infringes or violates the intellectual property, privacy, or publicity rights of others;
- reproduce, retransmit, distribute, disseminate, sell, publish, broadcast, or circulate content received through the Services to anyone without prior express permission;
- engage in unauthorized spidering, “scraping,” or harvesting of content or personal information, or use any other unauthorized automated means to compile information;
- take any action that imposes an unreasonable or disproportionately large load on our network or infrastructure;
- use any device, software, or routine to interfere or attempt to interfere with the proper working of the Services or any activity conducted on the Services or attempt to probe, scan, test the vulnerability of, or breach the security of any system or network;
- attempt to modify, translate, decipher, decompile, disassemble, reverse-engineer, or create derivative works of any of the software comprising or in any way making up a part of the Services; or
- engage in any other conduct that restricts or inhibits any person from using or enjoying the Services, or that, in our sole judgment, exposes us or any of our users, affiliates, or any other third party to any liability, damages, or detriment of any type.
Violations of system or network security may result in civil or criminal liability. We may investigate and work with law enforcement authorities to prosecute users who violate the Terms. We may suspend or terminate your access to the Services for any or no reason at any time without notice.
V. PAYMENT AUTHORIZATION
By providing a credit card or other payment method accepted by Operator (“Payment Method”), you are expressly agreeing that we are authorized to charge to the Payment Method any fees for your use of the Services, together with any applicable taxes. Please note that Operator may not receive complete information from your health insurance plan, if applicable, regarding the applicable co-pay due from you for your consultation. As such, you may be billed more than once with respect to a consultation to account for additional co-pay amounts due, if any.
You agree that authorizations to charge your Payment Method remains in effect until you cancel it in writing, and you agree to notify Operator of any changes to your Payment Method. You certify that you are an authorized user of the Payment Method and will not dispute charges for the Services that correspond to consultation fees or the co-payment required by your health plan. You acknowledge that the origination of ACH transactions to your account must comply with applicable provisions of U.S. law. In the case of an ACH transaction rejected for insufficient funds, Operator may at its discretion attempt to process the charge again at any time within 30 days.
When scheduling a visit with a Provider using the Services, you will be required to provide a Payment Method. If you choose to cancel your scheduled appointment, you must do so at least 24 hours in advance of the scheduled appointment time. Should you choose to cancel your scheduled appointment within 24 hours of the scheduled appointment time, Operator may assess a reservation fee.
You acknowledge and agree that fees for consultations may increase at any time.
VI. INTELLECTUAL PROPERTY RIGHTS
The Services are protected under the copyright laws of the United States and other countries. All copyrights in the Services are owned by us or our third-party licensors to the full extent permitted under the United States Copyright Act and all international copyright laws. You may not publish, reproduce, distribute, display, perform, edit, adapt, modify, or otherwise exploit any part of the Services without our written consent.
All rights in the product names, company names, trade names, logos, service marks, trade dress, slogans, product packaging, and designs of the Services, whether or not appearing in large print or with the trademark symbol, belong exclusively to Operator or its licensors and are protected from reproduction, imitation, dilution, or confusing or misleading uses under national and international trademark and copyright laws. The use or misuse of these trademarks or any materials, except as authorized herein, is expressly prohibited, and nothing stated or implied on the Services confers on you any license or right under any patent or trademark of Operator, its affiliates, or any third party.
VII. PASSWORD SECURITY
You are solely responsible for the security of your username and password, and for any use of the Services using your username and password. You should not share your username or password with any third party or allow any third party to access the Services using your username and password. You agree to notify us if you have any reason to believe that your username or password has been lost, compromised, or misused in any way. We reserve the right to revoke or deactivate your username and password at any time.
VIII. WEBSITE AND THIRD-PARTY CONTENT
Other than information received directly by you from Providers, the content on the Services should not be considered medical advice. You should always talk to an appropriately qualified health care professional for diagnosis and treatment, including information regarding which medications or treatment may be appropriate for you. NONE OF THE CONTENT ON THE SERVICES REPRESENTS OR WARRANTS THAT ANY PARTICULAR MEDICATION OR TREATMENT IS SAFE, APPROPRIATE, OR EFFECTIVE FOR YOU. Operator does not recommend or endorse any specific tests, providers, medications, products, or procedures.
The Services may provide links to third-party content. You acknowledge and agree that we are not responsible for the availability of such third-party content, and we do not control, endorse, sponsor, recommend, or otherwise accept responsibility for such content. Use of any linked third-party content is at the user’s own risk.
IX. CONSENT TO SERVICES
GENERAL CONSENT TO TELEHEALTH TREATMENT
By clicking the “AGREE” button, you acknowledge that you are consenting to receive the Services and that you request and authorize Ascension Medical Group, LLC and/or its subsidiary or affiliate (“AMG”) as my provider of telehealth services, including any subcontractors, assistants or designees (collectively “the providers”) may deem necessary or advisable. This care may include, but is not limited to, routine medical and nursing care that are appropriate for a telehealth visit. I understand that my (the patient’s) care is directed by my (the patient’s) providers, and that other personnel may render care and services to me (the patient) according to the providers’ instructions. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees or promises have been made to me with respect to the results of such diagnostic procedure or treatment. The provider will determine, in his or her sole discretion, whether or not the condition being diagnosed and/or treated is appropriate for telehealth services. The provider will determine, in his or her sole discretion, whether a prescription is appropriate to treat any condition and I understand that providers will not prescribe controlled substances through these telehealth services.
By clicking the “AGREE” button you acknowledge that you are consenting to receiving care via the Service. The scope of care will be at the sole discretion of the Provider who is treating you, with no guarantee of diagnosis, treatment, or prescription. The Provider will determine whether or not the condition being diagnosed and/or treated is appropriate for a telehealth encounter via the Service. The Service respects and upholds patient confidentiality with respect to protected health information as outlined by the Health Insurance Portability and Accountability Act (“HIPAA”), and, subject to HIPAA regulations, will obtain express patient consent prior to sharing any patient-identifiable information to a third party for purposes other than treatment, payment or health care operations. In addition, by clicking the “AGREE” button you are authorizing Online Care Network II P.C. (“OCN”), a physician group who may provide you with health care services via the Service, to release your contact information to American Well solely in order for American Well to provide you with information about additional clinical services or general wellness. You may opt out of receiving such information by contacting helpdesk support. Finally, when using the Service you may be asked if you would like to share certain PHI collected by Apple Health with the Services. By clicking on “SYNC” you are authorizing the Services to collect and Providers to utilize such PHI.
By clicking the “AGREE” button you also acknowledge the importance of providing a record of your clinical encounters via the Services to your primary care provider. At the end of your consultation, you will have the option to send this record to your primary care provider via email and we encourage you to do so.
X. CONSENT FOR TREATMENT PERFORMED BY OCN
We are providing this information on behalf of OCN:
Telemedicine involves the use of communications to enable health care providers at sites remote from patients to provide consultative services. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include live two-way audio and video and other materials (e.g., medical records, data from medical devices).
The communications systems used will incorporate reasonable security protocols to protect the confidentiality of patient information and will include reasonable measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. At the end of each encounter, the patient will be provided an encounter summary, which may be kept for the patient’s records and may be shared with the patient’s local primary care or other provider, as appropriate.
Anticipated Benefits of Telemedicine
- Improved access to medical care by enabling a patient to remain at his or her home or office while consulting a clinician.
- More efficient medical evaluation and management.
Possible Risks of Telemedicine
As with any medical procedure, there are potential risks associated with the use of telemedicine. OCN believes that the likelihood of these risks materializing is very low. These risks may include, without limitation, the following:
- Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment.
- Security protocols could fail, causing a breach of privacy of personal medical information.
- Lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other negative outcomes.
By accepting these Terms, you acknowledge that you understand and agree with the following:
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine; I have received the HIPAA Notice which explains these issues in greater detail.
- I understand that telemedicine may involve electronic communication of my personal medical information to medical practitioners who may be located in other areas, including out of state.
- I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
- I understand that my healthcare information may be shared with others (including health care providers and health insurers) for treatment, payment, and healthcare operations purposes. Psychotherapy notes are maintained by clinicians but are not shared with others, while billing codes and encounter summaries are shared with others and with me. If I obtain psychotherapy from OCN, I understand that my therapist has the right to limit the information provided to me if in my therapist’s professional judgment sharing the information with me would be harmful to me.
- I further understand that my healthcare information may be shared in the following circumstances:
a) When a valid court order is issued for medical records.
b) Reporting suspected abuse, neglect, or domestic violence.
c) Preventing or reducing a serious threat to anyone’s health or safety.
Patient Consent to the Use of Telemedicine
I have read and understand the information provided above, and understand the risks and benefits of telemedicine, and by accepting these Terms I hereby give my informed consent to participate in a telemedicine visit under the terms described herein.
XI. DISCLAIMER OF WARRANTIES; LIMITATION OF LIABILITY
YOUR USE OF THE SERVICES IS AT YOUR OWN RISK. THE SERVICES ARE PROVIDED “AS IS” WITHOUT WARRANTIES OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING WITHOUT LIMITATION WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, OR OTHER VIOLATION OF RIGHTS. WE DO NOT WARRANT THE ADEQUACY, CURRENCY, ACCURACY, LIKELY RESULTS, OR COMPLETENESS OF THE SERVICES OR ANY THIRD-PARTY SITES LINKED TO OR FROM THE SERVICES, OR THAT THE FUNCTIONS PROVIDED WILL BE UNINTERRUPTED, VIRUS-FREE, OR ERROR-FREE. WE EXPRESSLY DISCLAIM ANY LIABILITY FOR ANY ERRORS OR OMISSIONS IN THE CONTENT INCLUDED IN THE SERVICES OR ANY THIRD-PARTY SITES LINKED TO OR FROM THE SERVICES. SOME JURISDICTIONS MAY NOT ALLOW THE EXCLUSION OF IMPLIED WARRANTIES, SO SOME OF THE ABOVE EXCLUSIONS MAY NOT APPLY TO YOU.
IN NO EVENT WILL WE, OR OUR PARENTS, SUBSIDIARIES, AFFILIATES, LICENSORS, SUPPLIERS AND THEIR DIRECTORS, OFFICERS, AFFILIATES, SUBCONTRACTORS, EMPLOYEES, AGENTS, AND ASSIGNS BE LIABLE FOR ANY DIRECT OR INDIRECT, SPECIAL, INCIDENTAL, CONSEQUENTIAL OR PUNITIVE DAMAGES, LOST PROFITS, OR OTHER DAMAGES WHATSOEVER ARISING IN CONNECTION WITH THE USE OF THE SERVICES, ANY INTERRUPTION IN AVAILABILITY OF THE SERVICES, DELAY IN OPERATION OR TRANSMISSION, COMPUTER VIRUS, LOSS OF DATA, OR USE, MISUSE, RELIANCE, REVIEW, MANIPULATION, OR OTHER UTILIZATION IN ANY MANNER WHATSOEVER OF THE SERVICES OR THE DATA COLLECTED THROUGH THE SERVICES, EVEN IF ONE OR MORE OF THEM HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES OR LOSS. BECAUSE SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF INCIDENTAL OR CONSEQUENTIAL DAMAGES, OPERATOR’S LIABILITY IN SUCH JURISDICTIONS SHALL BE LIMITED TO THE MAXIMUM EXTENT PERMITTED BY LAW.
YOU AGREE THAT YOUR SOLE REMEDY FOR ANY CLAIM ARISING OUT OF OR CONNECTED WITH THE SERVICES WILL BE TO CEASE USING THE SERVICES.
YOU ACKNOWLEDGE AND AGREE THAT OPERATOR IS NOT ENGAGED IN THE PRACTICE OF MEDICINE AND THAT OPERATOR IS NOT DETERMINING APPROPRIATE MEDICAL USE OF THE SERVICES. OPERATOR, ITS LICENSORS, SUPPLIERS, AND ALL THIRD PARTIES WHO PROMOTE THE SERVICES OR PROVIDE YOU WITH A LINK TO THE SERVICES EXPRESSLY DISCLAIM ANY AND ALL LIABILITY RESULTING FROM THE DELIVERY OF HEALTHCARE VIA THE SERVICE, INCLUDING BUT NOT LIMITED TO LIABILITY FOR MEDICAL MALPRACTICE.
YOU AGREE TO INDEMNIFY, DEFEND AND HOLD US AND OUR PARENTS, SUBSIDIARIES, AFFILIATES, LICENSORS, SUPPLIERS AND THEIR DIRECTORS, OFFICERS, AFFILIATES, SUBCONTRACTORS, EMPLOYEES, AGENTS, AND ASSIGNS HARMLESS FROM AND AGAINST ANY AND ALL LOSS, COSTS, EXPENSES (INCLUDING REASONABLE ATTORNEYS’ FEES AND EXPENSES), CLAIMS, DAMAGES AND LIABILITIES RELATED TO OR ASSOCIATED WITH YOUR USE OF THE SERVICES AND ANY ALLEGED VIOLATION BY YOU OF THESE TERMS. WE RESERVE THE RIGHT TO ASSUME THE EXCLUSIVE DEFENSE OF ANY CLAIM FOR WHICH WE ARE ENTITLED TO INDEMNIFICATION UNDER THIS SECTION. IN SUCH EVENT, YOU SHALL PROVIDE US WITH SUCH COOPERATION AS WE REASONABLY REQUEST.
XIII. CHOICE OF LAW AND FORUM
The Services are intended for use by residents of the United States. We do not intentionally provide access to the Services to individuals located outside the United States. You agree that your access to and use of the Services will be governed by and will be construed in accordance with the laws of the Commonwealth of Massachusetts without regard to principles of conflicts of laws. You agree that any claim or dispute against us arising out of or relating to the Services must be resolved by a federal district court located in Boston, Massachusetts, unless agreed upon by all parties.
ADVANCE NOTICE OF NON-COVERAGE
Medicare and other commercial insurance plans do not pay for everything that you or your health care provider have good reason to think you need. At this time, we expect that Medicare will not pay for this service because this type of service is not covered by Medicare and not a Medicare benefit. We also expect that commercial insurance will not pay for this service.
WHAT YOU NEED TO DO NOW: Read this patient acknowledgement and notice so you can make an informed decision about your care and ask us any questions that you may have after you finish reading. This notice gives our opinion and is not an official Medicare decision or commercial insurance coverage decision. If you have any other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-623-4227/TTY: 1-877-486-2048). If you have any other question on commercial insurance billing, call your commercial insurance company. By providing your payment information, you are choosing to receive this health care service and acknowledge and agree that neither Medicare, Medicaid or any commercial insurance will be billed for this service and that you assume all financial responsibility of paying for this service.
These Terms constitute the entire agreement between you and us, superseding any prior or contemporaneous communications and proposals (whether oral, written or electronic) between you and us. In the event any provision of these Terms is held unenforceable, it will not affect the validity or enforceability of the remaining provisions and will be replaced by an enforceable provision that comes closest to the intention underlying the unenforceable provision. You agree that no joint venture, partnership, employment, or agency relationship exists between you and us as a result of these Terms or your access to and use of the Services.
Our failure to enforce any provisions of these Terms or respond to a violation by any party does not waive our right to subsequently enforce any terms or conditions of the Terms or respond to any violations. Nothing contained in these Terms is in derogation of our right to comply with governmental, court, and law enforcement requests or requirements relating to your use of the Services or information provided to or gathered by us with respect to such use.
CURRENT PROCEDURAL TERMINOLOGY (“CPT”)
CPT Copyright © 2016 American Medical Association. All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Applicable FARs/DFARs restrictions apply to government use.
CPT is a registered trademark of the American Medical Association.
Copyright ©2008-2014 Vidyo, Inc. This product includes Vidyo Software Libraries which are covered by one or more issued or pending United States patents, as more fully detailed on the Patent Notice page of Vidyo’s website http://www.vidyo.com/about/patent-notices/, as well as issued and pending international patents.
If you are see a provider while you are located in California, please be advised that medical doctors are licensed and regulated by the Medical Board of California (800-633-2322; www.mbc.ca.gov).
I hereby certify that I am located in my current state (indicate on next page), and agree to only interact with a Provider using the Services while I am present in that state. I acknowledge that my ability to access and use the Services is conditional upon the truthfulness of the certifications I make at the time of accessing a Provider, and that the Providers I access are relying upon this certification in order to interact with me.
I hereby certify that I am at least 18 years of age and am qualified under the laws of my state to make medical decisions on my own behalf. I acknowledge that my ability to access and use the Ascension Online Care system and information is conditional upon the truthfulness of my certification of age.