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Last updated: August 17, 2020
PM Pediatrics Anywhere | Telemedicine
Consent to Treat, Guarantee of Payment, and Acknowledgement of Notice of Privacy Practices
I. CONSENT TO TREAT: I, the patient identified below or the parent or legal guardian of the patient identified below (the “Patient”), consent for the Patient to receive telemedicine services from PM Pediatrics Anywhere (“PM Pediatrics”), including any diagnostic procedures, treatments and/or tests, that the physician(s), nurse practitioner(s) or physician assistant(s) (each, a “Provider”) determine to be necessary and advisable. I understand that the Patient will be provided with the name, credentials, licensure/certification, and qualifications of the Provider who will be providing the telemedicine services. I understand that, in some instances, such as when the Patient is in school or elsewhere, such telemedicine services may be provided to the Patient without the Patient’s parent or legal guardian being present during the consultation. I further understand that the Provider will not prescribe to the Patient any controlled substances under federal law.
I understand that telehealth technology will be used to connect the Patient with a Provider, and that such consultations may be conducted by videoconferencing, video images, high quality still images and/or by telephone conference. I consent and authorize PM Pediatrics to audio record, video record, and/or photograph the consultation as necessary for providing quality healthcare services via telehealth technology, which, in some cases, may be facilitated with the assistance of a school nurse or other facilitator who is not affiliated with or employed by PM Pediatrics. I understand that all or a portion of the recordings, videos or images may become part of the Patient’s medical record and that such information may be used for internal purposes, such as quality improvement or education. I understand that if such information is used externally for the advancement of medical knowledge or educational purposes, then the Patient’s identity will remain anonymous and that such uses will be governed by PM Pediatrics’ Notice of Privacy Practices.
I understand that PM Pediatrics offers real-time, remote, interactive telemedicine consultations to patients and, in some instances, may offer limited medical examinations through the use of a peripheral medical device (“PMD”) which can remotely examine the Patient’s vital signs and systems and transmit such information to the Provider for evaluation. I understand that in cases where a PMD is used, a school nurse or other facilitator may assist in the telemedicine consultation by conducting an examination using the PMD. The PMD is manufactured and distributed by an independent medical technology company which is not affiliated with PM Pediatrics.
I understand that PM Pediatrics has implemented security measures sufficient to protect the Patient’s electronic health information. Electronic health information is stored in a secure data center in encrypted format to prevent unauthorized individuals from viewing or accessing such data. PM Pediatrics also utilizes password and authentication protections as additional safeguards where appropriate.
In choosing to participate in a telemedicine consultation, I understand that the use of telemedicine technology for diagnosing or treating health conditions presents certain risks, including but not limited to the following, which may occur in rare instances:
I have been advised and understand all the potential risks, benefits and alternatives to telemedicine and choose to proceed with a telemedicine consultation. I hereby release and hold harmless PM Pediatrics from any loss of data or information due to technical failures.
In the event of an adverse reaction to treatment or if there is a telemedicine equipment failure, I understand that I may choose to re-initiate telemedicine services through the PM Pediatrics Anywhere platform or seek treatment from the Patient’s primary care provider, an urgent care facility, or emergency department as appropriate under the circumstances. I also understand that the Provider may terminate the consultation if he or she feels that telemedicine services are inappropriate under the circumstances and may direct the Patient to an emergency department, urgent care provider or specialist as appropriate. I understand that the Provider’s responsibility to provide medical services will end upon termination of the telemedicine consultation. I understand that I have the right to terminate the consultation at any time, without affecting the Patient’s right to future care or treatment.
I acknowledge that in cases of Patient disclosure of intent to harm self or others, or instances of past or present child neglect or abuse, disclosure and/or mandated reporting may result in accordance with applicable local, state or federal law and/or PM Pediatrics’ policies and practices.
I authorize PM Pediatrics to use and disclose my protected health information (“PHI”) as permitted under the Health Insurance Portability and Accountability Act (“HIPAA”), other applicable law, and by PM Pediatrics’ Notice of Privacy Practices. I hereby consent to PM Pediatrics accessing, storing and sharing my medical information electronically through health information exchanges pursuant to applicable state and federal law, including, without limitation, Carequality, a nationwide health information exchange. I understand that other healthcare providers within the Carequality network will have access to my health information for purposes of treatment, payment and healthcare operations and that I may choose to direct PM Pediatrics not to share my health information with other Carequality participants by submitting to PM Pediatrics a signed copy of the Carequality Opt-Out form (available upon request).
I understand that I will have access to the records pertaining to the Patient’s telemedicine treatment through the PM Pediatrics Anywhere platform. I may obtain copies of such records from the PM Pediatrics Anywhere platform for my own use or to disclose to the Patient’s primary care provider. Alternatively, I may request a copy of the Patient’s records by emailing firstname.lastname@example.org or by calling (516) 869-0650.
Policies Relating to School Telehealth Programs
I understand that some telemedicine consultations will be conducted with the assistance of a school nurse or other facilitator, who is not employed by or affiliated with PM Pediatrics. In such instances, I voluntarily consent for the school nurse or other facilitator of the medical examination to receive protected health information (“PHI”) in order to carry out the treatment of the Patient and to remain in the room, where necessary, to aid in the consultation. I agree that PM Pediatrics will not be responsible for the medical care, services, and treatment delivered by facilitators, nurses, physicians, or healthcare providers not employed by PM Pediatrics.
In instances where the telemedicine consultation is conducted by a school nurse, I hereby give permission and consent for the school nurse or other representatives of the school to release and exchange information about the Patient’s health history or other confidential personally identifiable information about the Patient to PM Pediatrics to aid in the telemedicine treatment. I acknowledge that information provided by the school to PM Pediatrics may be considered education records that are subject to the Family Educational Rights and Privacy Act and its implementing regulations (“FERPA”). I understand that PM Pediatrics will comply with any applicable FERPA or state law requirements regarding the confidentiality of education records that it may come to possess.
II. RELEASE OF INFORMATION: I hereby consent to the use and disclosure of the Patient’s health information for purposes of treatment, payment, and health care operations as described in the Notice of Privacy Practices. I hereby authorize and direct PM Pediatrics to release to government agencies, insurance carriers, managed care companies, or other entities who are or may be financially liable for the Patient’s medical care (and to authorized agents of such entities) all information needed to substantiate payment for this medical care and to permit representatives thereof to examine and request copies of records related to the Patient’s case and medical treatment. I further authorize PM Pediatrics to release billing information to any healthcare provider involved in the Patient’s care.
III. ASSIGNMENT: I hereby assign, transfer and set over to PM Pediatrics sufficient monies and/or benefits to which I am or may be entitled from government agencies, insurance carriers, or others who may be financially responsible for the Patient’s medical care to cover costs of the care and treatment rendered.
IV. PATIENT GUARANTEE OF PAYMENT: I accept that I am financially responsible for all services rendered on the Patient’s behalf for which a charge may be associated. I accept personal responsibility for all co-payments, deductibles, and non-covered services, as dictated by my or the Patient’s insurance coverage (hereinafter, the “insurance plan”), plus any collection costs for amounts personally owed by me. I acknowledge that services provided by PM Pediatrics may not be covered by the insurance plan for one or more reasons, including but not limited to exclusions under the insurance plan, exhaustion of benefits, the insurance plan’s designation of PM Pediatrics as an out-of-network provider, and/or my failure to provide the insurance card. I understand that if I do not fulfill the requirements of the insurance plan, do not receive the requisite prior approval, if the authorization is denied or if the insurance plan refuses to pay the cost of the telemedicine services for any other reason, I understand and agree that I am financially responsible for the cost of these services.
If the insurance plan sends me or the Patient money that is designated to pay for the services provided by PM Pediatrics, I agree to immediately send the check or an amount equal to the amount received by the insurance plan to PM Pediatrics. I understand that all bills are to be paid immediately upon receipt. I also understand that in the event my account is transferred to a collection agency due to my failure to pay for the services, that I will be responsible for any reasonable attorney’s fees and collection fees incurred by PM Pediatrics in collecting payment, in addition to the amount of the bill.
V. HIPAA ACKNOWLEDGEMENT: I acknowledge that I have reviewed and understand PM Pediatrics’ Notice of Privacy Practices containing a description of the uses and disclosures of my health information. I further understand that PM Pediatrics may update its Notice of Privacy Practices at any time, and that I may receive an updated Notice of Privacy Practices by submitting a request in writing to PM Pediatrics or by accessing the most current Notice of Privacy Practices online at pmpanywhere.com or www.pmpediatrics.com/telemedicineforms.
VI. COMMUNICATIONS: I understand that PM Pediatrics may need to contact me regarding the healthcare services provided to the Patient. I authorize PM Pediatrics to call the phone number I have provided and to leave voicemail messages with respect to the Patient’s clinical care, to facilitate treatment, payment and health care operations, and for quality improvement or educational purposes. I hereby consent to PM Pediatrics mailing materials incident to treatment, payment and health care operations to the address I have provided, such as billing statements and/or other materials containing PHI. I hereby consent to receive text messages and/or emails (generated through an automated system or otherwise) from or on behalf of PM Pediatrics for purposes of treatment, payment and health care operations, including, without limitation, quality improvement and patient satisfaction activities. I understand that PM Pediatrics cannot guarantee the privacy, security or confidentiality of text messages or email communications sent or received. I understand that I may opt-out of receiving automated emails or text messages at any time.
VII. AFFIRMATION: I affirm that I have read and fully understand this PM Pediatrics Anywhere – Telemedicine Consent to Treat, Guarantee of Payment, and Acknowledgement of Notice of Privacy Practices form and have been given the opportunity to ask questions and that all my questions have been answered to my satisfaction.