Consent/Request for Treatment

Introduction. Telemedicine involves the real-time evaluation, diagnosis, consultation on, and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video, or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real-time.

Consent for Treatment. I voluntarily request Vitavia Telemedicine physician(s) and other health care providers as they may deem necessary (“Vitavia Providers”) to participate in my medical care through the use of telemedicine. I understand that Vitavia Telemedicine Providers (i) may practice in a different location than where I present for medical care, (ii) may not have the opportunity to perform an inperson physical examination, and (iii) rely on information provided by me. I acknowledge that Vitavia Telemedicine Providers’ advice, recommendations, and/or decision may be based on factors not within their control, such as incomplete or inaccurate data provided by me or distortions of diagnostic images or specimens that may result from electronic transmissions. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure. If Vitavia Telemedicine Providers determine that the telemedicine services do not adequately address my medical needs, they may require an in-person medical evaluation. In the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented or an in-person medical evaluation may be necessary. If I experience an urgent matter, such as a bad reaction to any treatment after a telemedicine session, I should alert my treating physician and, in the case of emergencies dial 911, or go to the nearest hospital emergency department.

Release of Information. To facilitate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of all and any part of my medical record (including oral information) to Vitavia Telemedicine Providers. I understand and agree that the information I am authorizing to be released may include: 1) AIDS/HIV test results, diagnosis, treatment, and related information: 2) drug screen results and information about drug and alcohol use and treatment; 3) mental health information; and 4) genetic information. I understand that the disclosure of my medical information to Vitavia Telemedicine Providers, including the audio and/or video, will be by electronic transmission. Although precautions are taken to protect the con􀂦dentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images, and audio is new and developing technology and that con􀂦dentiality may be compromised by failures of security safeguards or illegal and improper tampering. I certify that this form has been fully explained to me, that I have read it or have had it read to me, and that I understand its contents.

Payment. I agree to pay for medical services rendered at Vitavia Telemedicine.

Notices. I understand that any and all records, whether written, oral or in electronic format are con􀂦dential and cannot be disclosed for reasons outside of treatment, payment or healthcare operations. I understand and have been provided with a notice of patient privacy handout that provides a more complete description of information uses and disclosures. A photocopy or fax of this consent is as valid as this original. I understand that I may revoke this consent, in writing, except where disclosures have already been made in reliance. I understand I can make a complaint of my provider to the Texas Medical Board by going online at http://www.tmb.state.tx.us/page/place-a-complaintor calling the Complaint Hotline at 800-201-9353.

I certify that I have read this document or have had it read to me. I understand and agree to its
contents.

Patient Complaint Procedure. While we hope every patient’s visit goes smoothly, it is important that we are notified of patient concerns so we can take the appropriate steps to address them. A patient has the right to communicate a verbal or written complaint or concern regarding any aspect of his/her visit (i.e. medical care, service, conditions, billing) and expect a timely response. If you have comments, questions, or concerns, we recommend that you or your representative: Discuss them with your immediate caregiver, or speak to the manager of the clinic or service in which you are receiving care. 

Complaints about physicians, as well as other licensees and registrants of Texas medical Board, 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, TX 78768-2018 Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353. For more information please visit the Texas medical Board website at www.tmb.state.tx.us If you are with a health maintenance organization and wish to file a complaint, you may do so by contacting the Texas Department of Insurance at 1-800-252-3439.

Notice of Privacy Practices. This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your personal and health information is important. This requires no action on your part unless you have a request or complaint. Vitavia Telemedicine, PLLC understands the importance of keeping your personal and health information private. Protected health information (PHI) includes both medical information and individually identi􀂦able information, such as your name, telephone number or social security number. We are required by applicable federal and state laws to maintain the privacy of your personal and health information. Both under law and by our policy, Vitavia Telemedicine has a responsibility to protect the privacy of your PHI. We will protect your privacy by limiting who may see your PHI; Limit how we may use or disclose your PHI; Inform you of our legal duties with respect to your PHI; Explain our privacy policies; and strictly adhere to the policies currently in effect. You have received this notice because you are under the care of, or are considering being treated by, or are considering being treated with, a product offered or administered by Vitavia Telemedicine. This is a notice of privacy practices, our legal duties and your rights concerning your PHI. We follow the privacy practices that are described in this notice while it is in effect. We reserve the right to change our privacy practices and the terms of this notice at any time, as allowed by applicable law, rules and regulations. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all PHI that we maintain, including information we created or received before we made the changes. When we make a signi􀂦cant change in our privacy practices, we will make the notice available to our patients, upon request, on or after the effective date of the change. For more information about our privacy practices, or for additional copies of this notice, please contact our o􀂨ce at the number listed at the end of this notice.

Uses and Disclosures of Patient’s Personal and Health Information as a patient of Vitavia Telemedicine, we may use and disclose your PHI without your consent/authorization, in the following ways:

• Treatment: We may disclose your PHI to a doctor, a hospital or other entity, which asks for it in order for you to receive treatment. 
• Payment: We may use and disclose your PHI to receive payment for services provided to you by our doctors, therapists, or other entities. This disclosure involves our business office staff and may include insurance organizations or other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances.
• Health Care Operations: We may use and disclose your PHI to keep our practice operable. Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, outside health or management reviewers and individuals performing similar activities.
• Family and Friends: If you are unavailable to communicate, such as in an emergency or disaster relief, we may disclose your PHI to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care. 
• Research: We may use or disclose your PHI for research purposes.
• Death: We may disclose the PHI of a deceased person to a coroner or medical examiner. 
• Organ Donation: We may use or share information for procurement, banking or transplantation of organs or tissue.
• Public Health and Safety: We may disclose your PHI to the extent necessary to avert a serious and imminent threat to your health or safety or the health or safety of others. We may disclose your PHI to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence or other crimes.
• Required by Law: We must use or disclose your PHI when we are required to do so by law: For example, we must disclose your PHI to the U.S. Department of Health and Human Services upon request for purposes of determining whether we are in compliance with federal privacy laws.
• Process and Proceedings: We may disclose your PHI in response to a court or administrative order, subpoena, discovery request or other lawful process. 
• Law Enforcement: We may disclose limited information to law enforcement officials concerning the PHI of a suspect, fugitive, material witness or missing person. We may disclose the PHI of an inmate or other person in lawful custody to a law enforcement official or correctional institution.
• Military and National Security: We may disclose to military authorities the PHI of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials PHI required for lawful intelligence, counterintelligence, and other national security activities authorizing use and disclosure of personal and health information.

Vitavia Telemedicine will request written authorization from you to use your PHI or to disclose it to anyone for any purpose or situation not included in this document. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. We will not use or disclose your PHI for any reason except those described in this notice without your written authorization. As a patient, the following are your rights concerning your: Your PHI: You have the right to review or obtain copies of your PHI, with certain exceptions. You may submit this request in writing by obtaining a form using the contact information listed at the end of this notice. If you request copies, we may charge you a reasonable, cost-based fee. You will be made aware of any and all charges prior to imposing such fee. Disclosure Accounting: You have the right to receive a list of instances in which we or our subcontractors disclosed your PHI for purposes other than treatment, payment and health care operations. We will maintain these types of disclosures for up to six (6) years. If you request this list more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. You may submit this request in writing by obtaining a form using the contact information listed at the end of this notice. 

Restriction Requests: You have the right to request that we place additional restrictions on our use or disclosure of your PHI. We are not required to agree to these additional restrictions, but if we do,  we will abide by our agreement (except in a need for your emergency treatment). You also have the right to agree to or terminate a previous submitted restriction. You may submit this request in writing by obtaining a form using the contact information listed at the end of this notice. Alternate Communication: You have the right to request that we communicate with you in confidence about your PHI by alternative means or to an alternative location. We will accommodate your request if it is reasonable and the request specifies the alternative means or location. If such a request is urgent, we will attempt to accommodate your request for alternative communications received verbally with the understanding that your written request follow at a later date. Routine requests may be submitted in writing by obtaining a form using the contact information listed at the end of this notice.

Amendment: You have the right to request that we amend your PHI. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended, we do not maintain the information or the information is deemed accurate and complete. If we deny your request, we will provide you a written explanation of the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment and to include the changes in any future disclosures of that information. You may submit this request in writing by obtaining a form using the contact information listed at the end of this notice.

Electronic Notice: You have the right to receive this notice in written form upon request. Please contact us using the information listed at the end of this notice to obtain this notice in written form.

If You Have a Complaint: If you are concerned that we may have violated your privacy rights or you disagree with a decision we made about access to your PHI, you may file a complaint with us using the contact information listed at the end of this notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to fille your complaint with the U.S. Department of Health & Human Services upon request.

If You Have a Request: If you would like to request a patient’s rights form, place an urgent request for alternate communications or file a complaint regarding your privacy rights, you may contact us at: Vitavia Telemedicine, PLLC -281-804-4861. We support your right to protect the privacy of your personal and health information. We will not retaliate in any way if you choose to fille a complaint with us or with the U.S. Department of Health and Human Services. It has always been goal to ensure the protection and integrity of our patients’ PHI. Therefore, we will notify you of any potential situations where your information would be used for reasons other than payment and health treatment operations.

Certain Waivers under HIPAA:

1. Patient acknowledges that neither Group nor Physician guarantees that communications with Physician using electronic mail ("e-mail"), facsimile, video chat, instant messaging, and cellular telephone are secure or confiddential methods of communications. Accordingly, Patient expressly waives Group’s and Physician’s obligations under the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. § 1320d et seq.), as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, and all rules and regulations promulgated thereunder (collectively, "HIPAA"), and other state and federal laws and regulations applicable to the use, maintenance, and disclosure of patient-related information, to guarantee confidentiality with respect to correspondence using such means of communication. Patient acknowledges that all such communications may become a part of Patient’s medical records maintained by Physician.
2. By providing Patient’s e-mail address to Physician, Patient authorizes Physician to communicate with Patient by e-mail regarding Patient’s "protected health information" ("PHI") (as defined under HIPAA) and Patient understands and agrees to the following: 
   • E-mail is not necessarily a secure medium for sending or receiving PHI and, accordingly, any third party may gain access to such PHI; 
   • Although Group and Physician will make all reasonable efforts to keep e-mail communications confidential and secure, neither Group nor Physician can assure or guarantee the absolute confidentiality of such e-mail communications.