New Patient Agreement, Informed Consent & HIPAA Notice of Privacy Practices
Marley Medical’s clinical care is provided by Marley Medical Provider Group, P.A. (“Provider Group”) and its contractual affiliates. Marley Medical connects you to a Provider Group physician or nurse practitioner to provide medical care and treatment. Marley Medical does not provide any medical services, does not practice medicine, and does not influence the practice of medicine or any licensed profession provided by Provider Group’s clinicians, each of whom are responsible for his or her services and compliance with the requirements applicable to his or her profession and license.
This New Patient Agreement (the “Agreement”), effective as of the date of the Patient’s signature (the “Effective Date”), is made by and between Marley Medical Provider Group, P.A., a Florida professional corporation and its contractual affiliates (“Practice”), and the undersigned patient (the “Patient,” “You” or “I” when making affirmative statements in this Agreement).You are a patient of the Practice who receives certain medical services from its clinicians using telehealth technologies (“Medical Services”).
Term, Termination, and Cancellation
This Agreement will commence on the Effective Date and will extend until after the consult(s).
You acknowledge that the signing of this Agreement is strictly voluntary. This Agreement does not restrict or limit your ability to receive professional services from other health care professionals.
Insurance or Other Medical Coverage
This Agreement and the Practice’s provision of Medical Services are not substitutes for health insurance or other health plan coverage (such as membership in an HMO). You acknowledge that the Practice has advised You to obtain or keep in full force your health insurance policy(ies) or plans in order to coverYou and your family members for Medical Services and other healthcare costs. You acknowledge that this Agreement is not a contract that provides health insurance for you, and this Agreement is not intended to replace any insurance coverage provided to You by an Insurer and that Medical Services are not intended to be billed to or covered by your Insurer. It is Your responsibility to submit any invoices paid for Medical Services to any health insurance or health plan coverage provider. The Practice in no way provides any representations to You that any Medical Services performed by the Practice will be eligible for coverage under any insurance policy held by You.
If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.
Modifications, Termination, Interruption, and Disruptions
You understand, agree and acknowledge that we may modify, suspend, disrupt or discontinue the Marley Medical platform, any part of the platform or the use of the platform, whether to all clients or to You specifically, at any time with or without notice to You. You agree and acknowledge that Provider Group will not be liable for any of the aforementioned actions or for the failure to provide any future Medical Services to You, or for any losses or damages that are caused by any of the aforementioned actions.
The Marley Medical platform depends on various factors such as software, hardware and tools, either our own or those owned and/or operated by our contractors and suppliers. While we make commercially reasonable efforts to ensure the platform’s reliability and accessibility, You understand and agree that no platform can be 100% reliable and accessible and so we cannot guarantee that access to the platform will be uninterrupted or that it will be accessible, consistent, timely or error-free at all times.
We may change this Agreement by posting modifications on the Marley Medical platform regarding the Medical Services. Unless otherwise specified by us, all modifications shall be effective upon posting. Therefore, You are encouraged to check the terms of this Agreement frequently. The last update to this Agreement is posted at the bottom of this Agreement. By using the MarleyMedical platform and the Medical Services after the changes become effective, You agree to be bound by such changes to the Agreement. If You do not agree to the changes, you must terminate your access to the Marley Medical platform and participation in the Medical Services.
Moreover, if federal, state, or local law or regulation (“Applicable Law”) requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of thisAgreement as though they had been expressly set forth in this Agreement.
This Agreement, and any rights You may have under it, may not be assigned or transferred by You. ThisAgreement, and any rights the Practice may have under it, may not be assigned or transferred to its heirs, successors, or assignees.
Relationship of Parties
You and the Practice intend and agree that the Practice, in performing the Medical Services under thisAgreement, is an independent contractor, as defined by the guidelines promulgated by the UnitedStates Internal Revenue Service and/or the United States Department of Labor, and the Practice shall have exclusive control of its work and the manner in which it is performed.
You acknowledge that this Agreement is a legal document and creates certain rights and responsibilities.You also acknowledge that You have had a reasonable time to seek legal advice regarding the Agreement and have either chosen not to do so or have done so and are satisfied with the terms and conditions of the Agreement.
All written notices are deemed delivered and received when sent if sent to the e-mail address of the party.
This Agreement shall be governed and construed under the laws of Missouri. This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted.
Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.
This Agreement contains the entire agreement between the parties regarding the subject matter of thisAgreement, and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement. If any provision of this Agreement is held by a court of competent jurisdiction to be illegal, invalid, unenforceable, or otherwise contrary to law, the remaining provisions of this Agreement will remain in full force and effect.
Medical Services Patient Warning. Patient understands and agrees that email and the internet should never be used to access medical care in the event of an emergency, or any situation that Patient could reasonably expect may develop into an emergency. Patient agrees that in such situations, when aPatient cannot speak to a physician or other appropriated license clinician that may provide MedicalServices hereunder (a “Clinician”) immediately in person or by telephone, that Patient shall call 911 or the nearest emergency medical assistance provider, and follow the directions of emergency medical personnel.
Background on Telemedicine:
Telemedicine involves the use of electronic communications technologies to enable the transfer of medical/health and other information between a health care provider and patient who are in different locations. Telemedicine technologies may include interactive two-way audio and video, interactive audio, remote monitoring, management of patient medical records, medical images, e-mail, output data from medical devices, and sound and video files. Information conveyed using telemedicine may be used for the diagnosis, treatment, follow-up and/or education of patients.
Electronic systems incorporate network and software security protocols to protect your confidentiality and the confidentiality of Your data, including that which is considered protected health information(“PHI”) as further defined under “Notice of Privacy Practices” below. Our system also includes measures to safeguard the data, including all PHI, and to ensure its integrity against intentional or unintentional corruption.
Expected Benefits of receiving Medical Services via Telemedicine:
• Improved access to medical care by enabling you to consult with your Clinician remotely.
• More efficient medical evaluation and management.
• Obtaining the expertise of a distant specialist.
Possible Risks of Receiving Medical Services via Telemedicine:
As with any medical procedure, there are potential risks associated with the use of telemedicine. 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 Clinician.
•Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information, including PHI.
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
• There may be other risks that are currently not known.
BY CLICKING ACCEPT, I ACKNOWLEDGE THAT I UNDERSTAND AND AGREE WITH THE FOLLOWING: 1. I give my informed consent to receive medical services including telemedicine from Practice, and its primary care practitioners and specialists (“Clinicians”) for myself or for the patient for whom I am the parent or legal guardian. This medical care may include services related to my health (or the identified person) and may include (but not be limited to) preventative care, diagnostic testing, therapeutic treatments, rehabilitative care, health maintenance, palliative care, counseling, assessment, or review of physical or mental status/function of the body. This consent includes contact and discussion with other health care professionals for care and treatment. 2. Marley Medical, Inc. ("Marley Medical") is a separate entity that is independent from the Practice, is not licensed to practice medicine, and has been contracted by the Practice to furnish administrative services for Practice and to assist with the provision of technologies and administrative services used to support telemedicine encounters. 3. It is up to the Practice Clinician to determine whether my needs are appropriate for a telemedicine encounter. 4.I will not be prescribed any controlled substance, as determined by any applicable federal or state agency, and there is no guarantee that i will receive a prescription for any medication. 5. 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. 6. Telemedicine may involve electronic communication of my personal medical information, including PHI, to Practice Clinicians or other healthcare providers who may be located in other areas, including in other states. 7. It is my duty to inform my Clinician of relationships I may have with other healthcare providers providing treatment to me to ensure my Clinician has a full clinical picture when making treatment decisions. 8. Some parts of the services involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of my Clinician. 9.I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. 10. I may suspend or terminate access to telemedicine services at any time for any reason or for no reason. 11. I understand that if I am experiencing a medical emergency, that I will be directed to dial 9-1-1 immediately and that neither Practice, nor Clinicians nor Marley Medical service specialists may be able to connect me directly to any local emergency services. 12. I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, including my medical record, and may receive copies of this information for a reasonable fee. 13. Video images and audio recordings of me may be captured and stored electronically. I understand that these recordings may be later viewed and used for purposes of evaluation and training, which may include Practice or Marley Medical non-clinical personnel. I understand and consent to the use of these images and audio recordings for the telemedicine consultation and, potentially, evaluation, education and training. 14. I understand that my healthcare information, including PHI, may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Clinicians in order to operate the telemedicine technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination; and/or (3) terminate the consultation at any time. 15. The laws that protect privacy and the confidentiality of medical information, particularly PHI, also apply to telemedicine, and that no information obtained in the use of telemedicine that identifies me will be disclosed to researchers or other entities without my express written consent. 16. I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured. 17. There is a risk of technical failures during the telemedicine encounter beyond the control of Practice and Marley Medical. I agree to hold harmless Practice and Marley Medical for delays in evaluation or for information lost due to such technical failures. 18. In the event of any problem with the website or related services, I agree that my sole remedy is to cease using the website or terminate access to the service. Under no circumstances will Practice and Marley Medical be liable in any way for the use of the telemedicine services, including but not limited to, any errors or omissions in content or infringement by any content on the website of any intellectual property rights or other rights of third parties, or for any losses or damages of any kind arising directly or indirectly out of the use of, inability to use, or the results of use of the website, and any website linked to the website, or the materials or information contained on any or all such websites. I agree that i will not hold the Practice nor Marley Medical liable for any punitive, exemplary, consequential, incidental, indirect or special damages (including, without limitation, any personal injury, lost profits, business interruption, loss of programs or other data on my computer or otherwise) arising from or in connection with your use of the website whether under a theory of breach of contract, negligence, strict liability, or otherwise, even if we or they have been advised of the possibility of such damages; provided however that I do not waive any right to bring valid malpractice claims against any Clinicians that have providedMedical Services to me. 19. Marley Medical makes no representation that materials on this website are appropriate or available for use in any other location. I understand that if I access these services from a location outside of the United States, that I do so at my own risk and initiative and that I am ultimately responsible for compliance with any laws or regulations associated with my use. 20. I have been offered a copy of this consent form.
All Clinicians that provide Medical Services on the Marley Medical platform hold professional licenses issued by the professional licensing boards in the states where they practice, hold doctoral degrees in medicine and have undergone post-doctoral training and/or other applicable experience and certification. You can report a complaint relating to services provided by any Clinician by contacting the professional licensing board in the state where the services were received. In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee.
You can find the contact information for each of the state professional licensing boards governing medicine on the Federation of State Medical Boards website at: http://www.fsmb.org/state-medical-boards/contacts
Any patient medical records created as a result of your use of the site will be securely maintained by thePractice on behalf of your treating Clinician for a period that is no less than the minimum number of years such records are required to be maintained under state and federal law, and which is typically at least six years.
Please report any violations of these New Patient Agreement and Informed Consent to: firstname.lastname@example.org
HIPPA Notice of Privacy Practices
Our Privacy Obligations
The law requires us to maintain the privacy of certain health information called "Protected HealthInformation" or "PHI". Protected Health Information is the information that you provide us or that we create or receive about your health care. The law also requires us to provide you with this Notice of our legal duties and privacy practices. When we use or disclose (share) your Protected Health Information, we are required to follow the terms of this Notice or other notice in effect at the time we use or share the PHI. Finally, the law provides you with certain rights described in this Notice. Furthermore, we are required to notify you following a breach of unsecured PHI.
This Notice describes the privacy practices of Practice. It applies to the health services you receive from the Practice. The Practice will be referred to herein as "we" or "us." We will share your health information among ourselves to carry out our treatment, payment, and health care operations.
Ways We Can Use and Share Your PHI Without Your Written Permission (Authorization)
In many situations, we can use and share your PHI for activities that are common in many hospitals and clinics. In certain other situations, which we will describe under "Uses and Disclosures Requiring Your Written Permission (Authorization).”
In some circumstances, we must have your written permission (authorization) to use and/or share yourPHI. We do not need any type of permission from you for the following uses and disclosures:
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND SHARED ANDHOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures for Treatment, Payment and Health Care Operations
We may use and share your PHI to provide "Treatment," obtain "Payment" for your Treatment, and perform our "Health Care Operations." These three terms are defined as: Definitions • Treatment. We use and share your PHI to provide care and other services to you--for example, to diagnose and treat your injury or illness. In addition, we may contact you to provide appointment reminders or information about treatment options. We may tell you about other health-related benefits and services that might interest you. We may also share PHI with other doctors, nurses, and others involved in your care. •Payment. We may use and share your PHI to receive payment for services that we provide to you. As an example, we may share your PHI with the person who you told us is primarily responsible for paying for your treatment, such as your spouse or parent. • Health Care Operations. We may use and share yourPHI for our health care operations, which include management, planning, and activities that improve the quality and lower the cost of the care that we deliver. For example, we may use PHI to review the quality and skill of our Clinicians. However, you have the right to restrict disclosure to a health plan for healthcare services for which you pay in full out of pocket (excluding a deductible). • BusinessAssociates. In addition, we may share PHI with certain others who help us with our activities, including those we hire to perform services. All such Business Associates are required to sign an agreement that protects your PHI.
Your Other Health Care Providers
We may also share PHI with your doctor and other health care providers when they need it to provideTreatment to you, to obtain Payment for the care they give to you, to perform certain Health CareOperations, such as reviewing the quality and skill of health care professionals, or to review their actions in following the law.
Disclosure to Relatives, Close Friends and Your Other Caregivers
We may share your PHI with your family member/relative, a close personal friend, or another person who you identify in writing to us if we: (1) first provide you with the chance to object to the disclosure and you do not object; (2) reasonably infer that you do not object to the disclosure; or (3) obtain your written permission to share your PHI with these individuals. If you are not present at the time we share your PHI, or you are not able to agree or disagree to our sharing your PHI because you are not capable or there is an emergency circumstance, we may use our professional judgment to decide that sharing the PHI is in your best interest. We may also use or share your PHI to notify (or assist in notifying) these individuals about your location and general condition.
Public Health Activities
We are required or are permitted by law to report PHI to certain government agencies and others. For example, we may share your PHI for the following: • to report health information to public health authorities for the purpose of preventing or controlling disease, injury, or disability; • to report abuse and neglect to government authorities, including a social service or protective services agency, that are legally permitted to receive the reports; • to report information about products and services to the U.S.Food and Drug Administration; • to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of developing or spreading a disease or condition; • to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance; and • to prevent or lessen a serious and imminent threat to a person for the public's health or safety, or to certain government agencies with special functions such as the State Department.
Health Oversight Activities
We may share your PHI with a health oversight agency that oversees the health care system and ensures the rules of government health programs, such as Medicare or Medicaid, are being followed.
Judicial and Administrative Proceedings
We may share your PHI in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.
Law Enforcement Purposes
We may share your PHI with the police or other law enforcement officials as required or permitted bylaw or in compliance with a court order or a subpoena.
We may share PHI with a coroner or medical examiner as authorized by law. We may share your PHI with a family member who was involved in your care or payment for your care prior to death, unless such disclosure would be inconsistent with any prior expression you have communicated to us. Under federal, the privacy rights described herein will expire fifty years after your death.
Organ and Tissue Procurement
We may share your PHI with organizations that facilitate organ, eye, or tissue procurement, banking, or transplantation.
We may use or share your PHI if the group that oversees our research, the Institutional Review Board/Privacy Board, approves a waiver of permission (authorization) for disclosure or for a researcher to begin the research process.
We may share your PHI as permitted by or required by state law relating to workers' compensation or other similar programs.
We may share your PHI to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.
School Immunization Requests
We may share your PHI for purposes of school immunization requests if the school is required by law to have documentation of such immunization(s) for enrollment.
We may contact you to raise funds for Practice. You may tell us you do not wish to be contacted for this purpose, and will agree to remove you from the list. To do so, please contact the HIPAA Privacy Officer at the address below.
As required by law we may use and share your PHI when required to do so by any other law not already referred to above.
Uses and Disclosures Requiring Your Written Permission (Authorization)
Use or Disclosure with Your Permission (Authorization)
For any purpose other than the ones described above under “Ways We Can Use and Share Your PHI Without Your Written Permission (Authorization),” we may only use or share your PHI when you grant us your written permission (authorization). For example, you will need to give us your permission before we send your PHI to your life insurance company.
We must also obtain your written permission (authorization) prior to using your PHI to send you any marketing materials paid for by a third party. However, we may communicate with you face to face about products or services related to your treatment, case management, or care coordination, or alternative treatments, therapies, health care providers, or care settings. In addition, we may not sell your PHI without your written authorization.
Uses and Disclosures of Your Highly Confidential Information
Federal and state law requires special privacy protections for certain highly confidential information about you ("Highly Confidential Information"), including: (1) any portion of your PHI that is kept in psychotherapy notes; (2) about mental health and developmental disabilities services; (3) about alcohol and drug abuse prevention, treatment and referral; (4) about HIV/AIDS testing, diagnosis or treatment; (5) about sexually transmitted disease(s); (6) about genetic testing; (7) about child abuse and neglect; (8) about domestic abuse of an adult with a disability; (9) about sexual assault; or (10) In Vitro Fertilization (IVF). Before we share your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written permission.
Your Rights Regarding Your Protected Health Information
If you want more information about your privacy rights, are concerned that we have violated your privacy rights, or disagree with a decision that we made about access to your PHI, you may contact our HIPAA Privacy Officer at the address below. You may also file written complaints with the Office for Civil Rights (“OCR”) of the U.S. Department of Health and Human Services by sending a letter to 200 Independence Avenue, S.W., Washington D.C. 20201, calling 1-877696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints. We will not take any action against you if you file a complaint with us or with the OCR.
Right to Receive Confidential Communications
You may ask us to send PHI to a different location than the address that you gave us, or in a special way, or to contact You at a different phone number. You will need to ask for this in writing. For example, You may ask us to send a copy of your medical records to a different address than your home address. We will accept all reasonable requests.
Right to Revoke Your Written Permission (Authorization)
You may change your mind about your authorization or any written permission regarding your PHI by giving or sending a written "revocation statement" to the HIPAA Privacy Officer at the address below. The revocation will not apply to the extent that we have already taken action where we relied on your permission.
Right to Inspect and Copy Your Health Information
You may request copies (for a reasonable fee) and/or access to your medical record file, billing records, and other records. You have a right to a copy of your records, if part of a “designated record set” in electronic format, as reasonably available. You can review your medical records and/or ask for hard copies. Under limited circumstances, we may deny you access to a portion of your records. If you want to access your records, you may obtain a record request form from Practice. Return the completed form to the HIPAA Privacy Officer at the address provided below.
Right to Amend Your Records
You have the right to request that we amend PHI maintained in medical record files, billing records, and other records used to make decisions about your Treatment and payment for your Treatment. If you want to amend your records, you may obtain an amendment request form from the HIPAA Privacy Officer. After which, you can return the completed form to the HIPAA Privacy Officer. We will comply with your request unless we believe that the information that would be amended is correct and complete or that other circumstances apply. In the case of a requested amendment concerning information about the Treatment of a mental illness or developmental disability, you have the right to appeal to a state court our decision not to amend your PHI.
Right to Receive an Accounting of Disclosures
You may ask for an accounting of certain disclosures of Your PHI made by us. These disclosures must have occurred before the time of Your request, and we will not go back more than six (6) years before the date of Your request. If you request an accounting more than once during a twelve (12) month period, we will charge You based on the rate sheet. Direct Your request for an accounting to the HIPAA Privacy Officer at the address provided below.
Right to Request Restrictions
You have the right to ask us to restrict or limit the PHI we use or disclose about You for treatment, payment, or health care operations. With one exception, we are not required to agree to Your request. If we do agree, we will comply unless the information is needed to provide emergency treatment. Your request for restrictions must be made in writing and submitted to the HIPAA Privacy Officer at the
address provided below. We must grant Your request to a restriction on disclosure of your PHI to a health plan if You have paid for Medical Services provided to you in full out of pocket.
Right to Receive a Copy of this Notice
If You ask, you may obtain a copy of this Notice, even if You have agreed to receive the notice electronically.
This Notice is effective as of December 14, 2021. Right to Change Terms of this Notice
Right to Change Terms of this Notice
We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all Protected Health Information that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the new notice in common areas throughout our facility, and on our Internet site at https://www.marleymedical.com/. You also may obtain any new notice by contacting the HIPAA Privacy Officer at the address provided below.
Federal & State Law
Federal and state laws require the Practice to protect your medical information and federal law requires Practice to describe to you how we handle that information. When federal and state privacy laws differ, and the state law is more protective of your information or provides you with greater access to your information, then state law will override federal law.
Questions or Concerns
You may contact the HIPAA Privacy Officer for additional information:
Address: 2858 University Ave, #266, Madison, WI 53705
Patient Bill of Rights
Many states have adopted a patient bill of rights applicable to patients of Clinicians and/or hospitals and other health care facilities. Some of those states require that physicians provide a copy of the bill of rights to their patients. The portion of the bill of rights that is relevant to any Medical Services provided to You here on behalf of Practice. Please note that it includes patient responsibilities as well. • A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy. • A patient has the right to a prompt and reasonable response to questions and requests within the context of the Service. • A patient has the right to know who is providing medical services and who is responsible for his or her care. • A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English. • A patient has the right to know what rules and regulations apply to his or her conduct. • A patient has the right to be given information by the health care provider concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis. • A patient has the right to refuse any treatment provided via the Service unless otherwise required by law. • A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and/or receipt and, upon request, to have the charges explained. • A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment, subject to the technical limitations of the Service. • A patient has the right to express grievances regarding any violation of his or her rights, as stated in state law, through the grievance procedure of the health care provider which served him or her and to the appropriate state licensing agency. • A patient is responsible for providing to the Provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health. • A patient is responsible for reporting unexpected changes in his or her condition to the Provider. • A patient is responsible for reporting to the Provider whether he or she comprehends a contemplated course of action and what is expected of him or her. • A patient is responsible for following the treatment plan recommended by the Provider. • A patient is responsible for his or her actions if he or she refuses treatment or does not follow the Provider’s instructions.
State Specific Notifications
FOR CALIFORNIA RESIDENTS • You or your legal representative retain the option to withhold or withdraw consent to receive health care services via the Medical Services at any time without affecting your right to future care or treatment nor risking the loss or withdrawal of any benefits to which You or Your legal representative would otherwise be entitled. • All existing confidentiality protections apply. • All existing laws regarding patient access to medical information and copies of medical records apply. • Dissemination of any of Your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without Your consent. • All provisions herein, including Your informed consent to receive services via the Service are for the benefit of the treating provider as well as for your benefit. • Medical doctors are licensed and regulated by the Medical Board of California, (800) 632-2322, www.mbc.ca.gov
FOR FLORIDA RESIDENTS • Each provider is a physician licensed by the Florida Board of Medicine or the Florida Board of Osteopathic Medicine. Each provider’s hours are variable. To access a provider’s in- office schedule, go to that provider’s login page where the provider’s in-office hours are posted.
FOR GEORGIA RESIDENTS • The patient has the right to file a grievance with the Georgia Composite Medical Board concerning the physician, staff, office, and treatment received. The patient should either call the Board with such a complaint or send a written complaint to the Board. The patient should be able to provide the physician or practice name, the address, and the specific nature of the complaint. The Georgia Composite Medical Board current phone number is (404) 656-3913 and the address is 2 Peachtree Street NW, 6th Floor, Atlanta, GA 30303-3465
FOR INDIANA RESIDENTS • Unless Your provider specifically discloses otherwise, with the exception of charges for services delivered to patients, providers do not have any financial interest in any information, products, or services offered through the Service. • I expressly consent to providers forwarding my patient identifiable information to the third-party payor responsible for the Service or its designee. I agree that I will hold harmless said payor(s), Marley Medical, the Practice and its Clinicians for any loss of information due to a technical failure. • You may access, supplement and amend your personal health information that you have provided to the Practice and its Clinicians and you may provide feedback regarding the site and the quality of information and services, and you may register complaints, including information regarding filing a complaint with the Consumer Protection Division Office of the Attorney General. Notice Concerning Complaints o You may either file a complaint online or download the appropriate complaint form. If downloading, you must complete, sign, print, and mail it, along with copies of all relevant supporting documentation to: § Consumer Protection Division Office of the Indiana Attorney General 302 W. Washington St., 5th Floor Indianapolis, IN 46204 § You can also request a complaint form by calling (800) 382-5516 or (317) 232-6330.
FOR KANSAS RESIDENTS • Notice to Patients o Required Signage for K.A.R. 100-22-6 Prepared by the State Board of Healing Arts April 5, 2007 o It is unlawful for any person who is not licensed under the Kansas Healing Arts Act to open or maintain an office for the practice of the healing arts in Kansas. Services are provided by a person who is licensed to practice the healing arts in Kansas • Questions and concerns regarding this professional practice may be directed to: o KANSAS STATE BOARD OF HEALING ARTS 800 SW Jackson, Lower Level – Suite A, Topeka, Kansas 66612 -- PHONE: (785) 296-7413 TOLL FREE: 1(888) 886-7205 FAX: (785) 368-7102 WEBSITE: www.ksbha.org
FOR LOUISIANA RESIDENTS • In addition to any informed consent and right to privacy and confidentiality pursuant to state and federal law or regulations, You shall be informed of the relationship between the Provider, you and the respective role of any other health care provider with respect to the management of Your care and treatment; and You may decline to receive Services and may withdraw from such care at any time.
FOR MARYLAND RESIDENTS • Our procedure to verify the identification of the individual transmitting the communication: •We verify Your identification through the assignment and use of a unique username and password combination. When You sign into the Service, your username and password identify You. • Access to data via the Service is restricted through the use of unique usernames and passwords. The username and password assigned to You are personal to You and You must not share them with any other individual. • When You choose a provider, You will set up an appointment time. Provider is hereby providing You with access to Provider’s notice of privacy practices. During the appointment, the provider will communicate with You and respond to Your questions in real time. • A primary difference between telehealth and direct in-person service delivery is the inability to have direct physical contact with You. • On occasion the Practice and its Clinicians may seek the advice of a consultant on Your behalf. In these cases, the knowledge, experience, and qualifications of the consultant providing data and information to the Practice need not be completely known to and understood by the Practice or its Clinicians. • The quality of transmitted data may affect the quality of Services provided by Marley Medical, the Practice or its Clinicians • Changes in the environment and test conditions could be impossible to make during delivery of Services. • Services may not be provided by correspondence only. Services must be delivered by either audio or audio-visual devices.
FOR MINNESOTA RESIDENTS • Disclosures of Your health records without Your written consent shall be made in accordance with state and federal law regarding privacy and confidentiality. Examples of such disclosures include, but are not limited to, for specific public health activities, for health oversight activities, for judicial and administrative proceedings, for specific law enforcement purposes. • You have the right to access and obtain copies of Your health records and other information about You that is maintained by the Practice. For more specific information regarding Your rights to access to health records, please refer to the Minnesota Department of Health Notices Related to Health Records at health.state.mn.us/facilities/notices/index.html
FOR OKLAHOMA RESIDENTS • You always retain the option to withhold or withdraw consent from obtaining health care services via the Service. If You decide that You no longer wish to obtain health care services via the Service, it will not affect Your right to future care or treatment, nor will You risk the loss or withdrawal of any program benefits to which You would otherwise be entitled. • Patient access to all medical information transmitted during a telemedicine interaction is guaranteed by Provider and copies of this information are available at stated costs, which shall not exceed the direct cost of providing the copies. • All existing confidentiality protections apply. • Dissemination of any of any of Your identifiable images or information from the telemedicine interaction to researches or other entities shall not occur without Your consent.
FOR OREGON RESIDENTS • You have choices with respect to receiving care and treatment from Practice. In this regard, You have a choice when You are referred to a facility or other health care provider by Practice for a diagnostic test or health care treatment, and may elect to receive the diagnostic test or other health care treatment from a facility or health care provider other than the one recommended by Practice. • If You choose to have the diagnostic test, health care treatment or service at a facility different from the one recommended by Practice, You are responsible for determining the extent or limitation of coverage for the diagnostic test, health care treatment or service at your chosen facility.
FOR TEXAS RESIDENTS • An additional in-person medical evaluation may be necessary to meet Your needs if the provider is unable to gather all the clinical information via the Service to safely treat You. • Unless Your provider specifically discloses otherwise, with the exception of charges for Services delivered to patients, providers do not have any financial interest in any information, products, or services offered through the Service. • The response time for emails, electronic messages and other communications can be found on Your provider’s login page. • 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 the website at www.tmb.state.tx.us
FOR VIRGINIA RESIDENTS • Practice will maintain your records while You are an active patient or will transfer your records to another practitioner or health care provider should You wish to seek care elsewhere. Practice shall maintain Your records for a minimum of six (6) years following Your last encounter with a Provider with the following exceptions: • Records of a minor child, including immunizations, must be maintained until the child reaches the age of 18 or becomes emancipated, with a minimum time for record retention of six years from the last patient encounter regardless of the age of the child; Records that have previously been transferred to another practitioner or health care provider or provided to the patient or his personal representative; or • Records that are required by contractual obligation or federal law to be maintained for a longer period of time. • Patient records will only be destroyed in a manner that protects patient confidentiality. • For more information from the Virginia Department of Health Professions, go to www.dhp.virginia.gov/Medicine. • Practice will obtain identification information on each patient. • Your Practice physician will introduce themselves and discuss their credentials at the time of Your first consultation. Information about each Practice Clinician can also be found on the Marley Medical website (https://www.marleymedical.com/). • Marley Medical and the Practice offer a variety of types of activities using telemedicine services. These include but are not limited to: diagnosis and management of both acute and chronic medical conditions, prescriptions, ordering of laboratory testing, radiographic studies, and other diagnostic testing, patient education, and appointment scheduling. • The patient agrees that it is the role of the physician to determine whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine encounter. • Marley Medical uses the latest security measures with the use of telemedicine services to ensure patient’s protected health information is secure. Marley Medical utilizes a secure server for storage of information. All computers are password protected and EMR is password protected. • Notwithstanding such measures there is still potential risk to privacy. • Patients will hold Marley Medical, the Practice and its Clinicians harmless for information lost due to technical failure. • Marley Medical, the Practice and its Clinicians will obtain expressed patient consent to forward patient-identifiable information to a third party.
FOR WISCONSIN RESIDENTS • You have the right to request and receive information within a reasonable period of time after your request the fees charged for a health care service, diagnostic test, or procedure provided by the Practice.