Corstrata Intake and Consent 12/2024

Welcome to Virtual Ostomy Support Services

At this time, Services may only be received in the following States:

AR, AZ, CA, CO, FL, GA, ID, IL, KY, LA, MA, MO, MS, NC, NJ, NM, NV, NY,

OH, OR, PA, RI, SC, TN, TX, VA, WA, WI

*More states coming soon*

Pricing - $80 for 45 minutes

*Corstrata services are private pay, out-of-pocket expenses, and are eligible for reimbursement with a FSA, HSA, and HRA.*
Primary Language*

EnglishSpanish
Is the patient?*

an adult (18+)a child (17 and under)/or has legal guardian
Legal Guardian Information
Legal Guardian's Name

First NameLast Name
Legal Guardian's Relationship to patient
Legal Guardian's Email
Legal Guardian's Phone Number
Patient Information
Patient's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Email
Phone Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact Information
In the event of a medical emergency during my virtual ostomy visit, I, the patient and/or the authorized signer for the patient, *

give consent for Corstrata to call my medical emergency contact and release my Protected Health Information to ensure proper medical care is provided.do NOT give consent for Corstrata to contact the medical emergency contact listed below.
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
How much time has it been since your surgery?

Less than 3 months3 to 12 monthsMore than 1 year
What type of ostomy do you have (Check all that apply)?*

ColostomyIleostomyUrostomyNot sureOther
What is the reason for scheduling a visit with our virtual support services? (Check all that apply)*

How to care for my ostomyIssues regarding my stoma or surrounding skinConcerns about my appliance - leakage, frequent changes, etc.Other
Was the patient born premature?

NoIf yes, gestational age at birth
Does the patient have other invasive devices or wounds?*

NoneGTTrachPICC/central lineOpen Wound/incisiónOther
How did you hear about Corstrata's ostomy support services?

Social media - i.e.Twitter, Instagram, Facebook, LinkedInFriend or family memberReferring providerProduct manufacturer or supplierOther
Is there anything else you would like to discuss
**Please note: Corstrata Virtual Support Services does NOT provide emergency medical care. If you think you may be experiencing a medical emergency please dial 911 immediately.**

Corstrata Virtual Ostomy Support Services Authorization & Consent (Click the arrow to the right to view authorization and consent)
Informed Consent for Remote Nursing Consultation
DIRECT TO CONSUMER
1. Introduction: Our (Corstrata Nursing Services, PC) nursing consultations involve the use of interactive audio, video, or other electronic communications to enable our wound and ostomy nurses at different locations to share individual patient medical information for the purpose of improving patient care as well as to engage in consultations regarding wound and ostomy care. The information gathered and discussed may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
  - Patient medical records
  - Medical images
  - 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 and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
2. Expected Benefits:
  - Improved access to care by enabling a patient to remain in his/her location, physician’s office, or at a remote site, while obtaining consultations with our wound and ostomy nurses at distant/other sites.
  - More efficient medical evaluation and management.
  - Obtaining expertise of a distant specialist nurses, that may not otherwise be available at the patient’s or their healthcare provider’s location.
3. Possible Risks: As with any similar services, there are potential risks associated with the use of telehealth related applications and services. These risks include, but may not be limited to:
  - In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s).
  - Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment. In the event the electronic services are interrupted due to a technology problem or an equipment failure, alternative means of communication may be necessary and/or an in-person medical evaluation with a local health care provider may be necessary.
  - In very rare 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 or allergic reactions or other judgment errors.In addition, remote nursing services will not allow our nurses to perform an in-person physical examination at the time the remote nursing consultation is provided, which could result in a failure to properly identify an ailment or condition that would otherwise have been properly addressed in an in-person consultation.
4. Alternatives: There are alternatives to remote nursing services. For instance, scheduling an appointment with a local healthcare provider may be available.
5. Acknowledgment: By signing this form, I understand the following:
  - I understand that the laws that protect privacy and the confidentiality of medical information also apply to remote nursing services, and that no information obtained in the use of remote nursing services which 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 remote nursing services in the course of my care at any time, without affecting my right to future care or treatment.
  - I understand that I have the right to inspect all information obtained and recorded in the course of a remote nursing interaction, and may receive copies of this information for a reasonable fee.
  - I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. My primary care physician has explained the alternatives to my satisfaction.
  - I understand that remote nursing services 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 it is my duty to inform my primary care physician of electronic interactions regarding my care that I may have with other healthcare providers and that I must rely on my primary care or other physician for all diagnosis and orders concerning my condition.
  - I understand that I may expect the anticipated benefits from the use of remote nursing services in my care, but that no results can be guaranteed or assured.
  - I understand that if, after a remote nursing consultation session, I experience any urgent medical symptoms or conditions, I will alert my treating physician or, in the case of an emergency, I will dial 911 or go directly to the nearest emergency room.
  - I understand that after any remote nursing consultation session, Corstrata’s nurses may give me guidance regarding any appropriate follow-up care and, if required by law, must share information regarding my nurse consultation services session with my primary care physician. I hereby authorize Corstrata and its nurses to share such information, which may include but is not limited to copies of my medical records, a report containing an explanation of the remote nursing services provided to me, and/or any evaluation, analysis, or diagnosis of my medical condition made by the Corstrata nurses.
  - I acknowledge that I have been given a copy of Corstrata’s privacy policy and notice of privacy practices. I understand that I am encouraged to review these documents prior to any consultation or evaluation by Corstrata’s nurses.
  - I have been given an opportunity to ask questions about the remote nursing consultation services to be provided to me, including any relevant risks and hazards involved with the provision of such services.
6. Patient Consent To Remote Nursing Consultation: I have read and understand the information provided above regarding remote nursing consultations, 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 hereby give my informed consent for the delivery of remote nursing consultations in my medical care. I hereby authorize Corstrata Nursing Services, PC to use remote nursing services in the course of my treatment. I also authorize Corstrata Nursing Services, PC (or one of its affiliates) to provide my name, address, and contact information to one or more medical device manufacturers or distributors in order to procure “samples” or other supplies on my behalf and will complete a HIPAA Authorization upon request for this purpose.
PATIENT PHOTOGRAPHIC AUTHORIZATION AND RELEASE
1. In connection with the medical services that I am receiving from Corstrata, I hereby authorize Corstrata to take photographs, slides, and video recordings of me or my child (or person for whom I am a legal guardian) or parts of my or their body in connection with one or more health conditions (the “Subject Images”) for medical purposes, for my or their care, for educational purposes, and for such other purposes authorized in this authorization and release (“Release”).
2. I understand and agree that the Subject Images may be used in my medical records, in medical presentations or articles, or in medical textbooks or journals, for medical instruction, for social media, for advertising and promoting services, for studies or research, and for statistical compilations by Corstrata, its affiliates, or its agents (the “General Purpose”), as well as for the purposes I have expressly designated below. By consenting to the use of the Subject Images, I understand that I will not receive payment from any person.
3. I further give authority to permit the modification or retouching of the Subject Images, and to the publication of information relating to my case, either separately or in connection with the publication of the Subject Images.
4. I will not be identified by name by Corstrata in any of the media described above and Corstrata will use its commercially reasonable efforts to maintain my anonymity; however, I also understand that (a) in some circumstances the photographs, slides, or video recordings may display features that may be used to identify me; (b) that Corstrata does not have control over the use of the Subject Images by third parties; and (c) my anonymity cannot be guaranteed. I have the right to revoke this authorization in writing at any time and, if I decide to do so, I must contact Corstrata’s privacy officer in writing. A revocation shall not affect any release of information made prior to revocation in reliance upon this Release, nor shall it be effective with respect to any third parties.
5. I may refuse to sign this Release without such refusal affecting the medical treatment I receive.
6. The information disclosed under this Release, or some portion of such information, may be protected by state law and the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by applicable federal and state confidentiality rules.
7. A copy of this Release is as valid as the original. I may inspect or copy information to be used or disclosed under this Release, as provided by federal and state law.
8. In such cases where the Subject Images will be used in the interest of medical education and knowledge, I grant this consent as a voluntary contribution and subject only to the condition that I will not be identified by name in the Subject Images. I certify that I have read this Release carefully and fully understand its terms.
9. I hereby authorize the use and disclosure of all Subject Images for any above-referenced purpose, including for:
  - The General Purpose;
  - Educational purposes, such as research and instruction;
  - Promotional purposes, e.g., with third party consultants to demonstrate typical Corstrata services or patients; and
  - Print and digital marketing advertisements.
10. I release and discharge Corstrata from all liability, including liability for negligence or liability that may result if my identity becomes known to the public despite Corstrata’s commercially reasonable efforts to maintain my privacy, and that in any way arises out of any and all rights that I may have or may have had in the Subject Images that I have authorized to be used and disclosed in this Release; any claim I may have against Corstrata for any use of the Subject Images by a third party; and any claim that I may have or may have had relating to such use and disclosure of the Subject Images.
11. A reference to “me” or “I” in this Release shall be deemed to also be a reference to the person for whom I am the legal guardian, as applicable.
12. I have read, understand and agree to this Release. I give unrestricted consent for photographic and electronic documentation of the Subject Images for use by Corstrata. My signature below attests my understanding of and agreement with this Release.
Updated 4/26/2024

List your Referring Provider's Name

First NameLast Name
List your Referring Provider's Name
Please enter a valid phone number.
Authorization for Release of Protected Health Information

I, the patient and/or the authorized signer for the patient, acknowledge and hereby authorize the release of my Protected Health Information, found on the Corstrata Visit Summary and/or Manufacturer Sampling Form, to the above listed referring provider. I may revoke this authorization at any time in writing to Corstrata, Inc. at P.O. Box 30643, Savannah, GA 31410 or via email at Support@Corstrata.com. If I do revoke this authorization, it will not have effect on any actions taken prior to receiving the revocation. Unless otherwise revoked, this authorization will expire in 90 days from the date of signature below.
Relationship to Patient - Self or (parent or legal guardian of the above-named minor, and have authority to execute this document)*

Self/PatientParentLegal GuardianOther
Print Name*
Date*

MonthDayYear
Date
By signing your signature below, you are confirming that you have read and understand the above, and agree to the terms of Corstrata's Virtual Ostomy Support Services.*

Clear

Ostomy Services*

Virtual Ostomy Support Visit45 minutes with a Certified Ostomy Nurse. Note - additional charges may apply if visit goes over allotted time. $25 per additional 15 minutes

$80.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Legal Guardian Information

Patient Information

Emergency Contact Information

**Please note: Corstrata Virtual Support Services does NOT provide emergency medical care. If you think you may be experiencing a medical emergency please dial 911 immediately.**

Informed Consent for Remote Nursing Consultation

Please note: Corstrata Virtual Support Services does NOT provide emergency medical care. If you think you may be experiencing a medical emergency please dial 911 immediately.