Conseas Telemedicine Policy #  

Informed Consent and Required Disclosures 

  

Purpose 

  

The purpose of this policy is to ensure that Conseas obtains the required informed consent and acknowledgement
forms from each patient prior to the evaluation or treatment of the patient in a Telemedicine encounter. 

  

Policy 

  

All Conseas staff and Matched Physician involved with the delivery of Telemedicine Services must ensure that signed copies of the following documents are obtained by prior to the start of a Telemedicine encounter: (i) notice of privacy practices, (ii) informed consent, and (iii) notice concerning complaints. 

  

Definitions: 

  

Matched Physician – the individual physician that was matched with the patient that is receiving the telemedicine services. 

  

Protected Health Information (“PHI”) – individually identifiable health information, including demographic information collected from an individual, that identifies, or can be used to identify, the individual and relates to: 

  

· The past, present, or future physical or mental health or condition of an individual; 

· The provisions of health care to an individual; or 

· The past, present or future payment for the provision of health care to an individual. 

  

Telemedicine Services – health care services delivered by a physician, or a health professional acting under
the delegation and supervision of a physician, to a patient at a different physical location than the physician or health professional using telecommunications or information technology. 

  

Procedure  

  

· Conseas staff and Matched Physician will ensure that all patients aged 18 years and older (or the parent, legal
guardian, or a lawfully authorized custodial agent for a minor child under the age of 18) will provide voluntary consent to treatment, on a Telemedicine Informed Consent form, prior to the delivery of a Telemedicine service. (See attached Telemedicine Informed Consent form) 

  

· Conseas staff and Matched Physician will ensure that all patients aged 18 years and older (or the parent, legal guardian, or a lawfully authorized custodial agent for a minor child under the age of 18) must voluntarily sign a notice of privacy practices and notice of the patient’s right to submit a complaint to the Texas Medical Board, prior to the delivery of a telemedicine service. (See attached Notice of Privacy Practices and Notice Concerning Complaints forms).

  

· Conseas staff and Matched Physician will give patients an opportunity to ask questions prior to signing the forms. 

  

· Matched Physician will fully inform patients of the consequences, benefits, and risks of treatment, after which patients have the right to decline Telemedicine Services.  

  

· Conseas staff and Matched Physician will maintain the executed forms in the patient’s medical record. 

 

Telemedicine Informed Consent Form 

  

Telemedicine services involve remote interactions through telecommunication technologies between a health care provider and a patient. The technologies may involve the use of telephone, video, or other two-way communication mediums, electronic patient portals, remote transmission and review of health information, or other methods. The
purpose of telemedicine is to enable evaluation, diagnosis, consultation, and treatment of a health condition without an in-person visit. 

Consent to Telemedicine 

I voluntarily consent to telemedicine services by [Physician Name], and any associates or technical assistants as they may deem necessary (“Telemedicine Providers”). 

  

I understand that I must provide information to the best of my knowledge and ability that is complete and accurate. This includes information about my medical history, condition(s), and current or previous medical care. 

  

I understand that Telemedicine Providers:  

• may be in a different location than the one where I may be physically present; 
• will not have the opportunity to perform an in-person, “hands-on” physical exam of me while using telemedicine services; and  
• must rely on information provided by me before and during our telemedicine encounter. 

  

I further understand that Telemedicine Services may be limited or unavailable as a result of technological or equipment failures, incomplete or inaccurate data to perform the telemedicine services, or distortions of images or other information from electronic transmissions.  

  

I acknowledge that the Telemedicine Providers cannot be held liable for advice, recommendations and/or decisions based on factors not within their control, such as incomplete or inaccurate data provided by me/others or distortions of diagnostic images or specimens that may result from electronic transmission. 

  

I understand that the level of care provided by Telemedicine Providers is to be the same level of care that is available to me through an in-person medical visit.  

  

If the Telemedicine Providers determine that the telemedicine services do not adequately address my medical needs, the Telemedicine Providers may suggest an on-site medical evaluation or may require me to seek in-person emergency medical attention or to schedule and attend an in-person appointment with my primary health care provider. 

  

I understand that if I experience any urgent medical symptom(s) or condition(s) after a telemedicine session, I
hould dial 911 or go directly to the nearest emergency room. 

  

I understand that the agreement between me and [Physician Name] for the provision of telemedicine services is not insurance, and that I am solely, financially responsible for the cost of such telemedicine services. 

  

I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services. I understand that this document will become a part of my medical record.  

  

I have been given an opportunity to ask questions about the telemedicine services to be provided to me. I understand
the risks and hazards involved with telemedicine services. I believe that I have enough information to give informed consent to receive telemedicine services by Telemedicine Providers. 

  

By signing this form, I attest that I: (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s). 

______________________________________ __________________________________
 

Patient/Parent/Guardian
Printed Name Patient/Parent/Guardian Signature  

  

______________________________________ 

Date  

  

NOTICE OF PRIVACY PRACTICES 

  

 

Effective Date: Revised on:   

  [Physician Name] [Address] [City, State, Zip] Tel: [Telephone Number] 

  

  

  

  

This Notice of Privacy Practices is NOT an authorization. It describes how we, our Business Associates, and their subcontractors may use and disclose your Protected Health Information (“PHI”) to carry out treatment, payment, or health care operations, and for other purposes that are permitted or required by law. It also describes your rights to
access and control your PHI. “PHI” is information that identifies you individually, including demographic information that relates your past, present, or future physical or mental health condition and related health care services. 

  

USES AND DISCLOSURES OF YOUR PHI we may use and disclose your PHI in the
following situations: 

  

· Treatment:
Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, we may disclose your
health information to others who may assist in your care, such as other healthcare providers, your spouse, your children or parent. 

  

· Payment:
Your health information may be used in order to bill and collect payment for the services and items you may receive from us. For example, we may use and disclose your health information to obtain payment from third parties that may
be responsible for such costs, such as family members. Also we may use your health information to bill you directly for services and items. 

  

· Health
Care Operations: We may use and disclose your PHI to manage, operate, and support the business activities of our practice. For example, information on the services you received may be used to support budgeting and financial reporting, activities to evaluate and promote quality, to develop protocols and clinical guidelines, to develop training programs, and to aid in credentialing medical review, legal services, and insurance. 

  

· Minors:
PHI of minors will be disclosed to their parents or legal guardians, unless prohibited by law. 

  

· Required
by Law: We will use or disclose your PHI when required to do so by local, state, federal, and international law.  

  

· Abuse,
Neglect, and Domestic Violence: Your PHI will be disclosed to the appropriate government agency if there is belief that a patient has been or is currently the victim of abuse, neglect, or domestic violence and the patient agrees or it is required by law to do so. In addition, your information may also be disclosed when necessary to prevent a serious threat to your health or safety or the health and safety of others to someone who may be able to help prevent the threat. 

  

· Judicial
and Administrative Proceedings: As sometimes required by law, we may disclose your PHI for the purpose of litigation to include: disputes and lawsuits; in response to a court or administrative order; response to a subpoena; request for discovery; or other legal processes. However, disclosure will only be made if efforts have been made to inform you of the request or obtain an order protecting the information requested. Your information may also be disclosed if required for our legal defense in the event of a lawsuit. 

  

· Law
Enforcement: We will disclose your PHI for law enforcement purposes when all applicable legal requirements have been met. This includes, but is not limited to, law enforcement due to identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or warrant, and grand jury subpoena. 

  

· Coroners
and Medical Examiners: We disclose PHI to coroners and medical examiners to assist in the fulfillment of their work responsibilities and investigations. 

  

· Public
Health: Your PHI may be disclosed and may be required by law to be disclosed for public health risks. This includes: reports to the Food and Drug Administration (FDA) for the purpose of quality and safety of an FDA-regulated product or activity; to prevent or control disease; report births and deaths; report child abuse and/or neglect; reporting of reactions to medications or problems with health products; notification of recalls of products; reporting a person who may have been exposed to a disease or may be at risk of contracting and/or spreading a disease or condition. 

  

· Health
Oversight Activities: We may disclose your PHI to a health oversight agency for audits, investigations, inspections, licensures, and other activities as authorized by law. 

  

· Inmates:
If you are or become an inmate of a correctional facility or under the custody of the law, we may disclose PHI to the correctional facility if the disclosure is necessary for your institutional health care, to protect your health and safety, or to protect the health and safety of others within the correctional facility. 

  

· Military,
National Security, and other Specialized Government Functions: If you are in the military or involved in national security or intelligence, we may disclose your PHI to authorized officials. 

  

· Immunizations:
We will provide proof of immunizations to a school that requires a patient’s immunization record prior to enrollment or admittance of a student in which you have informally agreed to the disclosure for yourself or on behalf of your legal dependent. 

  

· Worker’s
Compensation: We will disclose only the PHI necessary for Worker’s Compensation in compliance with Worker’s Compensation laws. This information may be reported to your employer and/or your employer’s representative regarding an occupational injury or illness. 

  

· Practice
Ownership Change: If our medical practice is sold, acquired, or merged with another entity, your PHI will become the property of the new owner. However, you will still have the right to request copies of your records and have copies transferred to another physician. 

  

· Breach
Notification Purposes: If for any reason there is an unsecured breach of your PHI, we will utilize the contact information you have provided us with to notify you of the breach, as required by law. In addition, your PHI may be disclosed as a part of the breach notification and reporting process. 

  

· Research:
Your PHI may be disclosed to researchers for the purpose of conducting research when the research has been approved by an Institutional Review or Privacy Board and in compliance with law governing research.  

  

· Business
Associates: We may disclose your PHI to our business associates who provide us with services necessary to operate and function as a medical practice. We will only provide the minimum information necessary for the associate(s) to perform their functions as it relates to our business operations. For example, we may use a separate Conseas to process our billing or transcription services that require access to a limited amount of your health information. Please know and understand that all of our business associates are obligated to comply with the same HIPAA privacy and security rules in which we are obligated. Additionally, all of our business associates are under contract with us and committed to protect the privacy and security of your PHI.  

  

USES AND DISCLOSURES IN WHICH YOU HAVE THE RIGHT TO OBJECT AND OPT OUT  

  

· Communication with family and/or individuals involved in your care or payment of your care: Unless you object,
disclosure of your PHI may be made to a family member, friend, or other
individual involved in your care or payment of your care in which you have
identified.  

  

· Disaster: In
the event of a disaster, your PHI may be disclosed to disaster relief organizations to coordinate your care and/or to notify family members or friends of your location and condition. Whenever possible, we will provide you with an opportunity to agree or object. 

  

· Fundraising: As necessary, we may disclose your PHI to contact you regarding fundraising events and efforts. You have the right to object or opt out of these types of communications. Please let our office know if you would NOT like to receive such communications. 

  

USES AND DISCLOSURES THAT REQUIRE YOUR WRITTEN AUTHORIZATION 

We will not disclose or use your PHI in the situations listed below without first obtaining written authorization to do so. In addition to the uses and disclosures listed below, other uses not covered in this Notice will be made only with your written authorization. If you provide us with authorization, you may revoke it at any time by submitting a request in writing to: [email address] 

  

· Disclosure of Psychotherapy Notes: Unless we obtain your written authorization, in most circumstances we will not disclose your psychotherapy notes. Some circumstances in which we will disclose your psychotherapy notes include the following: for your continued treatment; training of medical students and staff; to defend ourselves during litigation; if the law requires; health oversight activities regarding your psychotherapist; to avert a serious or imminent threat to yourself or others; and to the coroner or medical examiner upon your death. 

  

· Disclosures for marketing purposes and sale of your PHI 

  

PHI AND YOUR RIGHTS 

The following are statements of your rights, subject to certain limitations, with respect to your PHI: 

  

· You have the right to inspect and copy your PHI (reasonable fees may apply): Pursuant to your written request, you have the right to inspect and copy your PHI in paper or electronic format. Under federal law, you may not inspect or copy the following types of records: psychotherapy notes, information compiled as it relates to civil, criminal, or administrative action or proceeding; information restricted by law; information related to medical research in which you have agreed to participate; information obtained under a promise of confidentiality; and information whose disclosure may result in harm or injury to yourself or others. We have up to 30 days to provide the PHI and may charge a fee for the associated costs.  

  

· You have a right to a summary or explanation of your PHI: You have the right to request only a summary of your PHI if you do not desire to obtain a copy of your entire record. You also have the option to request an explanation of the
information when you request your entire record. 

  

· You have the right to obtain an electronic copy of medical records: You have the right to request an electronic copy of your medical record for yourself or to be sent to another individual or organization when your PHI is maintained in an electronic format. We will make every attempt to provide the records in the format you request; however, in the case that the information is not readily accessible or producible in the format you request, we will provide the record
in a standard electronic format or a legible hard copy form. Record requests may be subject to a reasonable, cost-based fee for the work required in transmitting the electronic medical records. 

  

· You have the right to receive a notice of breach: In the event of a breach of your unsecured PHI, you have the right to be notified of such breach. 

  

· You have the right to request Amendments: At any time if you believe the PHI we have on file for you is inaccurate or incomplete, you may request that we amend the information. Your request for an amendment must be submitted in writing and detail what information is inaccurate and why. Please note that a request for an amendment does not necessarily indicate the information will be amended.  

  

· You have a right to receive an accounting of certain disclosures: You have the right to receive an accounting of disclosures of your PHI. An “accounting” being a list of the disclosures that we have made of your information. The request can be made for paper and/or electronic disclosures and will not include disclosures made for the purposes of: treatment; payment; health care operations; notification and communication with family and/or friends; and
those required by law.  

  

· You have the right to request restrictions of your PHI: You have a right to restrict and/or limit the information we disclose to others, such as family members, friends, and individuals involved in your care or payment for your care. You also have the right to limit or restrict the information we use or disclose for treatment, payment, and/or health care operations. Your request must be submitted in writing and include the specific restriction requested, whom you want the restriction to apply, and why you would like to impose the restriction. Please note that our practice/your physician is not required to agree to your request for restriction with the exception of a restriction requested to not disclose information to your health plan for care and services in which you have paid in full out-of-pocket. 

  

· You have a right to request to receive confidential communications: You have a right to request confidential communications from us by alternative means or at an alternative location. For example, you may designate we send mail only to an address specified by you which may or may not be your home address. You may indicate we should only call you on your work phone or specify which telephone numbers we are allowed or not allowed to leave messages on. You do not have to disclose the reason for your request; however, you must submit a request with specific instructions in writing. 

  

· You have a right to receive a paper copy of this notice: Even if you have agreed to receive an electronic copy of this Privacy Notice, you have the right to request we provide it in paper form. You may make such a request at any
time.  

  

CHANGES TO THIS NOTICE 

We reserve the right to change the terms of this notice and will notify you of such changes. We will also make copies
available of our new notice if you wish to obtain one. We will not retaliate against you for filing a complaint. 

  

COMPLAINTS 

If at any time you believe your privacy rights have been violated and you would like to register a complaint, you may
do so with us or with the Secretary of the United States Department of Health and Human Services.  

  

If you wish to file a complaint with us, please submit it in writing to our Privacy/Compliance Officer to the address listed on the first page of this Notice. 

  

If you wish to file a complaint with the Secretary of the United States Department of Health and Human Services, please go to the website of the Office for Civil Rights (www.hhs.gov/ocr/hipaa/), call 202-619-0257 (toll free 877-696-6775), or mail to: 

  

 Centralized
Case Management Operations 

U.S. Department of
Health and Human Services 

 200
Independence Ave S.W. 

 Room
509F HHH Bldg. 

 Washington,
D.C. 20201 

  

  

 

  

[Physician Name] [Telephone Number] [email address]  

PRIVACY OFFICER PHONE EMAIL 

  

We are required by law to provide individuals with this notice of our legal responsibilities and privacy practices with respect to PHI. We are also required to maintain the privacy of, and abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our Privacy Officer in person or by phone at the number listed above. 

  

  

  

Acknowledgment of receipt of HIPAA Notice of Privacy Practices 

  

Patient's written name: ____________________________________________ 

Patient's Signature/Representative: __________________________________  

Date:
____________  

Relationship with Patient: ______________________________  

Signature of witness: _______________________  

  
 

  

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. 

  

  

  

  

______________________________________ _____________________________________
 

Patient/Parent/Guardian Printed Name Patient/Parent/Guardian Signature  

  

__________________________________ 

Date
 

AVISO SOBRE LAS QUEJAS 

Las quejas sobre médicos, así como sobre
otros

profesionales acreditados e inscritos del Consejo

Medico de Tejas, incluyendo asistentes de

médicos, practicantes de acupuntura y asistentes

de cirugía, 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 

  

  

  

______________________________________ _____________________________________
 

Nombre impreso del paciente/padre/tutor Firma
del paciente/padre/tutor 

  

__________________________________ 

Fecha