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 offered by Papa Docs, P.C. and its affiliates (collectively the “Group”), and the Group’s engaged affiliates practices,  providers, care advocates, social workers, nurses, or other integrated healthcare allied professionals (collectively “Providers” or your “Provider”) may include a patient consultation, diagnosis, treatment recommendation, care coordination referral, social work consults, prescription, medical order, or other letter of medical necessity, and/or follow up for in-person care, as determined clinically appropriate (the “Services”).  Papa Community (“Papa”) does not provide the Services; it performs administrative, payment, and other supportive activities for Group and its Providers.

Electronic Transmissions:

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

• Appointment scheduling, reminders, and notice of available benefits; 

• Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and your Provider via: 

  • asynchronous communications in combination with store-and-forward technology; 
  • two-way interactive audio in combination with store-and-forward communications; and/or 
  • two-way interactive audio and video interaction;
• Treatment recommendations or care referrals 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 and care referrals, 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. 

• 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 sending a secure message through your account portal. Please note that emergency messages should not be directed through secure messaging. 

• More efficient care evaluation and management. 

Service Limitations:

• The primary difference between telehealth and direct in-person service delivery is the inability to have 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 PAPA DOCS P.C., 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 for you to visit us. 

Security Measures

The electronic communication systems we use incorporate network and software security protocols to protect the confidentiality of patient information include measures to safeguard the data and its integrity against intentional or unintentional corruption.  All the Services delivered to the patient through telehealth are intended to be delivered over a secure connection that complies with applicable laws. Use of the Service may include email communications, phone calls, and text messages to and from you that may include your protected health information. You understand that Papa Community does not and cannot guarantee the security or privacy of the services you use to receive communications, including for example your email service provider.

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 the Group by emailing community-support@papa.com or 786-432-0117. 
• In rare events, your Provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or necessitating an in-person meeting with your local primary care doctor.
• In very rare events, security protocols and safeguards in the electronic communications could fail, causing a breach of privacy of personal medical information. 
• Your provider may not have access to your complete medical records, which could increase the risk of the care that is recommended, coordinated, or other clinical errors. 
• Legal or regulatory limitations may affect the types of diagnoses, treatments, prescriptions, and healthcare services your Provider can offer via telehealth.
• You may need to seek in-person, alternative, or emergency care if we cannot help you through the Services.

Open Payments Notice

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

Assignment of Benefits 

I hereby instruct and authorize my Insurance Company/Provider to make payments to Papa Community (hereinafter “Papa Community”) directly, via check or any other means acceptable, for all medical and incidental healthcare services provided by Papa Community. I understand that this assignment of benefits means that all Insurance Company payments for covered services provided will be made directly to Papa Community, and I agree to Papa Community being designated as a Representative Payee and attorney-in-fact, when necessary, for the limited purpose of receiving all payments due under my insurance benefits for services rendered. If my current policy prohibits direct payment to the provider of service, I instruct my Insurance Company to make out the check to me and mail payment directly to Papa Community at 390 NE 191st St., Suite 1705, Miami, FL 33179 for the professional or medical expense benefits otherwise payable to me under my current insurance policy as payment towards the total charges due. Upon receipt of said check, I authorize Papa Community to endorse such checks for deposit only, and to deposit and apply all the proceeds toward payment on my account.

I understand that as a courtesy to me, Papa Community will file a claim with my Insurance Company on my behalf. I also acknowledge and understand that I am financially responsible for, and hereby do agree to pay in a timely manner, any applicable deductibles, co-payments, or charges not covered by my Insurance Company. I understand that Actual Plan Benefits for provided services cannot be determined until the claim is received and processed by my Insurance Company, and that payment for services is based upon the Insurance Company’s determination of medical necessity. Moreover, I understand that submission of any claim for medical services is not a guarantee of payment. 

If it is necessary to file a formal collection action, I agree to pay all costs, including reasonable attorney’s fees incurred by Papa Community in the collection of the outstanding fees. 

Appointment of Representative:

I appoint Papa Community, to act on my behalf in connection with any claim for coverage or benefits identified in this case, including receipt of any approval(s) or authorization(s) that are required before medical service(s) are provided, or in order to receive any payments due under my insurance benefits for the service(s) Papa Community provided. I authorize my representative to receive any and all information related to this case that is provided to me and to provide any information to the health plan in relation to the disputed claims, approvals, or authorizations. This information may include a diagnosis (name of illness or condition), progress notes or other supporting documentation, claims, doctors and other health care providers and financial information (like billing and banking). I also understand that I may revoke (or cancel) this approval at any time, and that this Appointment shall cease as soon as Papa Community has received payment in full and remedies under applicable regulatory guidelines for all medical care services provided to me. I hereby confirm and ratify all action taken by my Representative pursuant to the authority granted herein. 

Authorization for Release for Records

I hereby authorize representatives of Papa Community, to receive any and all records and information pertinent to any claim or insurance benefit for the provided medical services that I am requesting approval for or seeking payment be issued. This request includes records and information related to ‘sensitive’ health information. I authorize my Insurance Company to release these records pertinent to the services provided by Papa Community to any third party deemed necessary. Moreover, I understand, agree, and allow Papa Community. to use and release my information as I have stated above. I also understand that signing this consent is of my own free will. I have the right to withdraw this approval at any time by giving written notice of my withdrawal to Papa Community. I understand that I cannot cancel this approval when this form has already been used to disclose information.

I understand that my withdrawal of this approval will not affect any action taken before I do so. I also understand that information that’s released may be given out by the person or group who receives it. If this happens, it may no longer be protected under the HIPAA Privacy Rule. I am entitled to a copy of this consent.

Patient Acknowledgments:

By clicking “I Agree”, checking a related box to signify your acceptance, using any other acceptance protocol presented through the Service or otherwise affirmatively accepting this consent, you are agreeing and providing your consent and understanding with respect to the following:

• Prior to the telehealth visit, I have been given an opportunity to review the Provider’s credentials, as appropriate, and I have elected to visit with the next available provider from Group, or have been given the opportunity to request another Group Provider. 
• If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and I understand that 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 at any time in the course of care I may receive without affecting my right to future care or treatment by emailing the Group at community-support@papa.com. Otherwise, this Telehealth Informed Consent will be considered renewed upon each new telehealth consultation with a Provider.
• I understand that my information, including my identifiable and sensitive health information, will be collected, used, shared, and protected as described in the Privacy Policy to the extent applicable. 
• 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 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 in accordance with the terms of the Privacy Policy or for purposes of my treatment 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 the Groups.  
• Persons may be present during the telehealth visit other than my Provider who will be participating in, observing, or listening to my consultation with my Provider (e.g., 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 their care recommendations, and the risks and benefits of various care options.
• I have the right to request a copy of my medical care 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: community-support@papa.com. A copy will be provided to me at a 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 contact community-support@papa.com or call 786-432-0117 at any time to access, amend, or review my health information.
• There is no guarantee that I will receive or be eligible for certain care from the Provider, and that the decision of whether care or other services are appropriate will be made in the professional judgment of my Provider. If my Provider issues a prescription or other referral for care, I have the right to select the pharmacy of my choice or other provider that I so choose to receive care from.
• 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.  
• If I am seeking reimbursement through my insurance for services, I have authorized Papa Community as my Authorized Representative to seek coverage of such claims and services that may be covered by my insurance, and to appoint Papa as my authorized representative for release of records related to payment of such services, and any services provided by Papa Community. 

Additional State-Specific Disclosures

The following disclosures and notices apply to patients accessing Group’s website for the purposes of participating in a telehealth consultation as required by the states listed or records request below: 

Alaska: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. 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.

California: Physicians and midwifes are regulated by the Medical Board of California. To confirm a license or file a complaint, go here or call (800) 633-2322. 

Connecticut: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

Georgia: 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.

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.

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.

Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter within three days of me providing consent to the person providing telemedicine services to send such report.

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.

New Hampshire: I understand that my primary care provider or treating provider may obtain a copy of my records of my telehealth encounter.

New Jersey: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter which may be forward directly to my primary care provider, or other provider, upon my request.

New York: I have been informed that to get information regarding your rights and how to report professional misconduct, I should visit 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.

Ohio: I understand that my primary care provider or treating provider may obtain a copy of my records of my telehealth encounter.

Oregon: 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.

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 understand that with my consent my medical records may be sent to my primary care physician within 72 hours after receiving telehealth services. I have also 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.

Wyoming: 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.