Telehealth Informed Consent

Cardiac Health Medical Group—Telehealth Informed Consent

This form describes Cardiac Health Medical Group's telehealth treatment policies and includes

Your consent to receive medical treatment from Cardiac Health Medical Group (and your other rights and responsibilities);
Your agreement to receive services using telehealth technology; and
Your agreement to pay in full any charges that are your responsibility.

Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care. This “Telehealth Informed Consent” informs the patient ("patient,” “you,” or “your") concerning the treatment methods, risks, and limitations of using a telehealth platform.

Services Provided:

Telehealth services are offered by Florida Cardiac Health Medical Group and its affiliated entities ("Group"), and the Group's engaged providers (our “Providers” or your “Provider") and may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services").

AliveCor Services, LLC and its parent AliveCor, Inc. do not provide the Services; rather, AliveCor Services, LLC performs administrative, payment, and other supportive activities for Group and our Providers.

Electronic Transmissions:

The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:

Appointment scheduling;
Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices, e.g., KardiaMobile®, and associated software, e.g., Kardia; sound and video files; diagnostic and/or lab test results) between you and your Provider via:
- asynchronous (not in real time) communications;
- two-way interactive audio in combination with store-and-forward communications; and/or
- two-way interactive audio and video interaction;
Treatment recommendations by your Provider based upon such review and exchange of clinical information;
Delivery of a consultation report with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant;
Prescription refill reminders (if applicable); and/or
Other electronic transmissions for the purpose of rendering clinical care to you.

Expected Benefits:

Improved access to care by enabling you to remain in your preferred location while your Provider consults with you. Our telehealth services are available on a flexible basis based on your location, but at least during the hours of 8am-8pm at least Mon-Fri.
Convenient access to follow-up care. If you need to receive non-emergent follow-up care related to your treatment, please contact your Provider by scheduling another appointment or contact your personal physician, and if urgent contact emergency care by dialing 911.
More efficient care evaluation and management. For example: you may schedule a visit with a board certified cardiologist within 48 hours of requesting an appointment and your Provider will have immediate access to your data from KardiaMobile in order to provide you with relevant, immediate and on-demand cardiological services.

Service Limitations:

The primary difference between telehealth and direct in-person service delivery is that telehealth does not provide direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.
OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IF YOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1 AND/OR GO TO THE NEAREST EMERGENCY ROOM. PLEASE DO NOT ATTEMPT TO CONTACT ALIVECOR SERVICES, GROUP, OR YOUR PROVIDER. AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER.
Our Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not.
Group does not have any in-person clinic locations.

Security Measures:

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification, ECG and other electronically recorded/stored data (“Data”) and will include measures to safeguard the Data and to ensure its integrity against intentional or unintentional corruption. All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

Possible Risks:

Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or provider availability.
In the event of an inability to communicate as a result of a technological or equipment failure, please contact technical support at 1 (855) 338-8800 and/or write an email to support@alivecor.com.
In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor.
In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

Patient Acknowledgments:

I further acknowledge and understand the following:

Prior to the telehealth visit, I have been provided the opportunity to review my Provider's credentials.
If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and my Provider is not able to connect me directly to any local emergency services.
I may elect to seek services from a medical group with in-person clinics as an alternative to receiving telehealth services.
I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment. I understand that absent the withdrawing of my consent given herein, that this consent will apply to all subsequent telehealth consultations with Group.
Federal and state law requires health care providers to protect the privacy and the security of health information. I am entitled to all confidentiality protections under applicable federal and state laws. I understand all medical reports resulting from the telehealth visit are part of my medical record.
Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication or transmission of my personal health information to other health practitioners who may be located in other areas, including out of state. I consent to Group using and disclosing my health information for purposes of my treatment (e.g., prescription information) and care coordination, to receive reimbursement for the services provided to me, and for Group's health care operations.
Dissemination of any patient-identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my consent unless authorized by state or federal law.
There is a risk of technical failures during the telehealth visit beyond the control of Group.
In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., ECG reviews, labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.
Persons may be present during the telehealth visit other than my Provider in order to operate the telehealth technologies. If another person is present during the telehealth visit, I will be informed of the individual's presence and his/her role.
My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.
I have the right to request a copy of my medical records. I can request to obtain or send a copy of my medical records to my primary care or other designated health care provider by contacting Group at: support@alivecor.com to affirmatively request a copy to be sent. A copy will be provided to me at reasonable cost of preparation, shipping and delivery.
It is necessary to provide my Provider a complete, accurate, and current medical history. I understand that I can log into my Kardia account at any time to access, amend, or review my health information stored in my .
There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgement of my Provider. If my Provider issues a prescription, I have the right to select the pharmacy of my choice.
There is no guarantee that I will be treated by a Group provider. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.

Additional State-Specific Consents: The following consents apply to patients accessing Group's website for the purposes of participating in a telehealth consultation as required by the states listed below:

Alaska: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website, here.

Iowa: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website, here.

Idaho: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website, here.

Indiana: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website, here.

Kentucky: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website, here.

Maine: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website, here; Or, the Maine Board of Osteopathic Licensure's website, here.

Oklahoma: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website, here; Or, the Oklahoma Board of Osteopathic Examiners’ website, here.

Rhode Island: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website, here.

Texas: I have been informed of the following notice:

NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.

Vermont: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board's website, here; Or, the Vermont Board of Osteopathic Examiners’ website, here.

NOTICE OF PRIVACY PRACTICESCARDIAC HEALTH MEDICAL GROUPAFFILIATED COVERED ENTITY

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices (the “Notice”) describes how Florida Cardiac Health Medical Group, P.A. d/b/a Cardiac Health Medical Group (“Cardiac Health Medical Group”) and the members of its Affiliated Covered Entity (collectively “we” or “our”) may use and disclose your protected health information to carry out treatment, payment or business operations and for other purposes that are permitted or required by law. An Affiliated Covered Entity is a group of health care providers under common ownership or control that designates itself as a single entity for purposes of compliance with the Health Insurance Portability and Accountability Act (“HIPAA”). We have elected to voluntarily substantially comply with the standards set forth in HIPAA. The members of the Cardiac Health Medical Group Affiliated Covered Entity will share protected health information with each other for the treatment, payment, and health care operations of the Cardiac Health Medical Group Affiliated Covered Entity and as permitted by HIPAA and this Notice of Privacy Practices. For a complete list of the members of the Cardiac Health Medical Group Affiliated Covered Entity, please contact the Cardiac Health Medical Group Privacy Office at TeleHealthPrivacy@alivecor.com.

“Protected health information” or “PHI” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical health or condition, treatment or payment for health care services. This Notice also describes your rights to access and control your protected health information.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION:

Your protected health information may be used and disclosed by our health care providers, our staff, and others outside of our office that are involved in your care and treatment for the purpose of: (1) providing treatment to you; (2) obtain payment for your care; (3) support our healthcare operations; and (4) any other use or disclosure authorized or required by law.

TREATMENT:
We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a health care provider to whom you have been referred to ensure the necessary information is accessible to diagnose or treat you.
PAYMENT:
Your protected health information may be used to bill or obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for your services, such as: making a determination of eligibility or coverage for insurance benefits and reviewing services provided to you for medical necessity.
HEALTH CARE OPERATIONS:
We may use or disclose, as needed, your protected health information in order to support the business activities of this office. These activities include, but are not limited to, improving quality of care, providing information about treatment alternatives or other health-related benefits and services, developing or maintaining and supporting computer systems, legal services, and conducting audits and compliance programs, including fraud, waste and abuse investigations.
USES AND DISCLOSURES REQUIRED BY LAW
We may use or disclosure your protected health information to the extent required by law.

DISCLOSURES THAT DO NOT REQUIRE YOUR AUTHORIZATION:

public health: for purposes including preventing and controlling disease, reporting child abuse or neglect, reporting domestic violence and reporting to the Food and Drug Administration regarding the quality, safety and effectiveness of a regulated product or activity.
health care oversight purposes: to a health oversight agency for authorized activities such as audits, investigations, inspections, licensing and disciplinary actions relating to the healthcare system or government benefit programs.
abuse or neglect reporting
pursuant to Food and Drug Administration requirements
in connection with legal proceedings:
law enforcement purposes: in response to an order from a court or administrative agency, or in response to a subpoena or discovery request.
in case of death: to coroners, medical examiners and funeral directors for purposes such as identification, determining the cause of death and fulfilling duties relating to death of the user.
organ procurement: for the purposes of organ donation and transplantation
certain research purposes: under appropriate circumstances as necessary for research purposes
;for certain criminal activities
certain military activity and national security purposes: for persons who are, or were, in the military to ensure proper execution of a military mission or determining entitlement to benefits. PHI may also be disclosed to federal officials for intelligence and national security purposes.
workers’ compensation reporting: as authorized by, and to the extent necessary to comply with, workers’ compensation programs and other similar programs relating to work-related illnesses or injuries
other required uses and disclosures. when required by the Secretary of the Department of Health and Human Services Under the law, we must make certain disclosures to investigate or determine our compliance with the requirements of the Health Insurance Portability and Accountability Act (HIPAA). State laws may further restrict these disclosures.

USES AND THAT REQUIRE YOUR AUTHORIZATION:

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless permitted or required by law. Without your authorization, we are expressly prohibited from using or disclosing your protected health information for marketing purposes. We may not sell your protected health information without your authorization. Your protected health information will not be used for fundraising. If you provide us with an authorization for certain uses and disclosures of your information, you may revoke such authorization, at any time, in writing, except to the extent that we have taken an action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION:

You have the right to inspect and copy your protected health information.

You may request access to or an amendment of your protected health information.

You have the right to request a restriction on the use or disclosure of your protected health/personal information. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. We are not required to agree to a restriction that you may request, except if the requested restriction is on a disclosure to a health plan for a payment or health care operations purpose regarding a service that has been paid in full out-of-pocket.

You have the right to request to receive confidential communications from us by alternative means or at an alternate location. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications.

You have the right to request an amendment of your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to our statement and we will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures of your protected health information that we have made, paper or electronic, except for certain disclosures which were pursuant to an authorization, for purposes of treatment, payment, healthcare operations (unless the information is maintained in an electronic health record); or for certain other purposes.

You have the right to obtain a paper copy of this Notice, upon request, even if you have previously requested its receipt electronically by e-mail.

REVISIONS TO THIS NOTICE:

We reserve the right to revise this Notice and to make the revised Notice effective for protected health information we already have about you as well as any information we receive in the future. You are entitled to a copy of the Notice currently in effect. Any significant changes to this Notice will be posted on our web site. You then have the right to object or withdraw as provided in this Notice.

BREACH OF HEALTH INFORMATION:

We will notify you if a reportable breach of your unsecured protected health information is discovered. Notification will be made to you no later than 60 days from the breach discovery and will include a brief description of how the breach occurred, the protected health information involved and contact information for you to ask questions.

COMPLAINTS:

Complaints about this Notice or how we handle your protected health information should be directed to our HIPAA Privacy Officer. If you are not satisfied with the manner in which a complaint is handled you may submit a formal complaint to the Department of Health and Human Services, Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

We must follow the duties and privacy practices described in this Notice. We will maintain the privacy of your protected health information and to notify affected individuals following a breach of unsecured protected health information. If you have any questions about this Notice, please contact our HIPAA Privacy Officer at TeleHealthPrivacy@alivecor.com.