SWELL CLINIC LLC
For avoidance of any doubt, the terms “Swell Clinic LLC”, “we”, “us”, or “our” refer to SWELL CLINIC LLC, and the terms “I”, “you”, and “yours” refer to the client using the Service and Website and App (collectively, the “Platform”).
CONSENT FOR TELEHEALTH CONSULTATION
1. I understand that I am voluntarily engaging in a telemedicine consultation with SWELL CLINIC LLC.
2. I understand that the video conferencing technology and/or phone consultations will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.
3. I understand that a telehealth consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation that I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. 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/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
6. I understand that the alternative to a telemedicine consultation is to forgo evaluation and treatment with SWELL CLINIC LLC and to seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a telemedicine consultation.
7. I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through SWELL CLINIC LLC will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all.
8. Telemedicine services offered through SWELL CLINIC LLC are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care.
9. To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment.
By signing this form, I certify:
· That I have read or had this form explained/read to me and I understand its contents including the risks and benefits of telemedicine.
· That I have had the opportunity to ask questions and have had them answered to my satisfaction.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Our PLEDGE REGARDING HEALTH INFORMATION:
We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this practice. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to:
- Make sure that protected health information (“PHI”) that identifies you is kept private.
- Give you this notice of our legal duties and privacy practices with respect to health information.
- Follow the terms of the notice that is currently in effect.
- We can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website.
II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. We may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a health care provider were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the health care provider in diagnosis and treatment of your condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
- Exam Notes: We do keep Exam Notes and any use or disclosure of such requires your Authorization unless the use or disclosure is:
a. For our use in treating you.
b. For our use in training or supervising associates to help them improve their clinical skills.
c. For our use in defending SWELLCLINIC LLC in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the session notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
- Marketing Purposes. As a health care clinic, we will not use or disclose your PHI for marketing purposes.
- Sale of PHI. As a health care clinic, we will not sell your PHI in the regular course of our business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:
- When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
- For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
- For health oversight activities, including audits and investigations.
- For judicial and administrative proceedings, including responding to a court or administrative order, although our preference is to obtain an Authorization from you before doing so.
- For law enforcement purposes, including reporting crimes occurring on our premises.
- To coroners or medical examiners, when such individuals are performing duties authorized by law.
- For research purposes, including studying and comparing the patients who received one form of care versus those who received another form of care for the same condition.
- Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
- For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.
- Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with us. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that we offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
- Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
- The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say “no” if we believe it will affect your health care.
- The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
- The Right to Choose How We Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
- The Right to See and Get Copies of Your PHI. Other than “session notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost based fee for doing so.
- The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost based fee for each additional request.
- The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that we correct the existing information or add the missing information. we may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request.
- The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on 16SEP2020
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.
PRACTICE POLICIES
APPOINTMENTS AND CANCELLATIONS
The standard meeting time for all visits is 10-15 minutes and they are over the phone.
We currently only see patients in the states of Arizona and Nevada. If you schedule an appointment and are not a resident of Arizona or Nevada, you will be subject to the cancellation policy.
Initial payment of $25 is due at the time of your appointment reservation. If further fees, services, or labs are ordered the payment for those will be due at the time of your appointment completion.
Cancellations and re-scheduled visits will be subject to a charge of $25 if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you.
We will call you at the appointment time. If you do not answer at the appointment time you will need to call us back during your appointment window and your appointment time may be shortened to accommodate. If you miss your appointment window and you still wish for care, you will need to reschedule your appointment.
TELEPHONE ACCESSIBILITY
If you need to contact SWELL CLINIC LLC between sessions, please call our main number or send us a message through the website. We are often not immediately available; however, we will attempt to return your call or message within 24 hours. If a true emergency situation arises, please call 911 or go to your local emergency room.
ELECTRONIC COMMUNICATION
We cannot ensure the confidentiality of any form of communication through electronic media, including, but not limited to, text messages, telephone communication, the Internet, facsimile machines, and e-mail. Telemedicine is broadly defined as the use of information technology to deliver medical services and information between two parties that are at different locations. The above electronic means of communication are considered telemedicine. Utilizing telemedicine services through SWELL CLINIC LLC is voluntary in nature and you need to understand:
1. You have the right to withhold or withdraw your consent for telemedicine services at any time. If this occurs, you need to understand that we cannot provide care for you any longer as SWELL CLINIC LLC is strictly a telemedicine practice.
2. We will protect your protected health information in the same fashion as a brick and mortar practice. You need to understand though that data breaches can happen, and we cannot assure your information is 100% protected.
3. We will not use your protected health information for research purposes unless you give us consent to do so.
4. There are potential benefits, risks and subsequent consequences of telemedicine. Potential benefits include, but are not limited to improved access to care, reducing costs, improving the quality of visits, and reduction of travel time associated with medical visits. The medical provider will make assessments, diagnoses, and treatment plans based off all the visual and auditory information provided during the video conference. You must understand that this is limited and posts potential risks including, but not limited to the provider’s inability to make complete diagnostic assessments that might require a physical exam and to see the patient in person. During an in-person encounter, a medical provider has the ability to see the entire patient including but not limited to their gait, smell, general appearance, and demeanor. Potential consequences thus include the provider not being aware of clinically significant information that you may not recognize as significant to present verbally to the provider.
MINORS
We require parental consent for all visits done through telemedicine. We require your parents to be present during a portion of the visit to ensure that they are consenting to treatment.
If you are a minor, your parents may be legally entitled to some information about your treatment. We will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
TERMINATION
We can terminate treatment with you at any time. We will not terminate the medical relationship with you without first discussing and exploring the reasons and purpose of terminating. If treatment is terminated for any reason, we will provide you with a list of qualified providers to continue your care. You may also choose someone on your own or from another referral source. Should you fail to show up for your follow up appointments, not obtain lab work in a timely fashion, or are non-compliant with treatment, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued.
I UNDERSTAND THAT BY CLICKING ON THE CHECKBOX I AM AGREEING TO THE FOREGOING ACKNOWLEDGEMENTS AND DISCLOSURES INCLUDING CONSENT FOR TELEHEALTH CONSULTATION, NOTICE OF PRIVACY PRACTICES, AND PRACTICE POLICIES. FURTHER, FOR PURPOSES OF INFORMED CONSENT, MY ACT OF CHECKING THE BOX SHALL CONSITIUTE MY ELECTRONIC SIGNATURE AND ON-GOING AGREEMENT TO THESE TERMS OF USE (IN WHATEVER FORM)