Telemedicine Consent to Treat, Guarantee of Payment, and Acknowledgement of Notice of Privacy Practices – PM Pediatrics Anywhere

PM Pediatrics Anywhere | Telemedicine

Note: THE PROVISIONS CONTAINED HEREIN DO NOT APPLY TO TELEMEDICINE VISITS INITIATED BY A SCHOOL NURSE OR OTHER FACILITATOR THROUGH A SCHOOL TELEMEDICINE PROGRAM. Such visits shall be governed by the Consent to Treat and Guarantee of Payment form executed by the patient’s parent or legal guardian in connection with the patient’s enrollment in the program.

I. CONSENT TO TREAT: I, the patient or the parent or legal guardian of the patient presenting for medical care (the “Patient”), consent for the Patient to receive medical care in person at PM Pediatric Care, WakeMed Children’s PM Pediatrics Urgent Care or Children’s Health^SM PM Urgent Care (each, the “Practice”) and/or through the Practice’s telemedicine platform (“PM Pediatric Telemedicine”).  Such medical care shall include any diagnostic, radiological and/or therapeutic procedures, treatments and/or tests that the physician(s), nurse practitioner(s), or physician assistant(s) (each, a “Provider) determine to be necessary and advisable (including, but not limited to, diagnostic x-rays, pharmaceutical products or medications, and blood tests).  I give the Practice the authority to dispose of the specimens taken for laboratory and pathology examination. I acknowledge that in cases of Patient disclosure of intent to harm self or others, or instances of past or present child neglect or abuse, disclosure and/or mandated reporting may result, in accordance with applicable local, state or federal law and/or the Practice’s policies and practices. I consent to and authorize the Practice to take photographs, audio recordings, videos and/or films (hereinafter, “media”) related to the care and treatment of the Patient and understand that such media may be made part of the Patient’s medical record and/or may be used for internal purposes, such as quality improvement or education. I understand that if such media is used externally for the advancement of medical knowledge or educational purposes, that the Patient’s identity will remain anonymous and that such uses will be governed by the Practice’s Notice of Privacy Practices.

Telemedicine Services

If the Patient receives telemedicine services, I understand that the Patient will be provided with the name, credentials, licensure/certification, and qualifications of the Provider who will be providing the telemedicine services. I understand that, in some instances, such as when the Patient is in school, camp or elsewhere, such telemedicine services may be provided to the Patient without the Patient’s parent or legal guardian being present during the consultation. I understand that telehealth technology will be used to connect the Patient with a Provider, and that such consultations may be conducted by videoconferencing, video images, high quality still images and/or by telephone conference. I consent and authorize the Practice to audio record, video record, and/or  photograph the consultation as necessary for providing quality healthcare services via telehealth technology, which, in some cases, may be facilitated with the assistance of a school nurse or other facilitator who is not affiliated with or employed by the Practice.

In choosing to participate in a telemedicine consultation, I understand that the use of telemedicine technology for diagnosing or treating health conditions presents certain risks, including but not limited to the following, which may occur in rare instances:

• Transmitted information may be distorted or insufficient to allow for appropriate medical decision making;
• There may be unanticipated delays in diagnoses or treatments due to equipment or technology failures or deficiencies;
• The Provider’s lack of access to complete medical records may result in adverse drug interactions, allergic reactions, or other medical decision errors;
• Records of services provided may be lost through technical failures; and
• In rare cases, security protocols could fail, causing a breach of privacy of personal medical information.

If the Patient is seeking telemedicine services in connection with this visit, I acknowledge that I have been advised and understand all the potential risks, benefits and alternatives to telemedicine and choose to proceed with a telemedicine consultation. I release and hold harmless the Practice from any loss of data or information due to technical failures.

In the event of an adverse reaction to the telemedicine treatment or if there is a telemedicine equipment failure, I understand that I may choose to re-initiate telemedicine services through the PM Pediatric Telemedicine platform or seek treatment from the Patient’s primary care provider, an urgent care facility, or emergency department as appropriate under the circumstances.  I also understand that the Provider may terminate the telemedicine consultation if he or she feels that telemedicine services are inappropriate under the circumstances and may direct the Patient to an emergency department, urgent care provider or specialist as appropriate. I understand that the Provider’s responsibility to provide medical services will end upon termination of the telemedicine consultation.  I understand that I have the right to terminate the consultation at any time, without affecting the Patient’s right to future care or treatment.

If telemedicine services are rendered, I understand that I may request to have the records relating to the telemedicine services sent to the Patient’s primary care provider.  To obtain copies of such records or request such record transfer, please visit pmpediatriccare.com or call (516) 869-0650.

School/Camp Telemedicine Programs

I understand that some telemedicine consultations will be conducted with the assistance of a school or camp nurse or other facilitator (“Facilitator”), who is not employed by or affiliated with the Practice.  In such instances, I voluntarily consent for the Facilitator to receive protected health information (“PHI”) in order to carry out the treatment of the Patient and to remain in the room, where necessary, to aid in the consultation.  I agree that the Practice will not be responsible for the medical care, services or treatment delivered by a Facilitator not employed by the Practice.

I understand that the Practice may offer limited medical examinations through the use of a peripheral medical device (“PMD”) which can remotely examine the Patient’s vital signs and systems and transmit such information to the Provider for evaluation.  I understand that in cases where a PMD is used, a Facilitator may assist in the telemedicine consultation by conducting an examination using the PMD.  The PMD is manufactured and distributed by an independent medical technology company which is not affiliated with the Practice.

In instances where the telemedicine consultation is conducted by a school nurse, I give permission and consent for the school nurse or other representatives of the school to release and exchange information about the Patient’s health history or other confidential personally identifiable information about the Patient to the Practice to aid in the telemedicine treatment.  I acknowledge that information provided by the school to the Practice may be considered education records that are subject to the Family Educational Rights and Privacy Act and its implementing regulations (“FERPA”).  I understand that the Practice will comply with any applicable FERPA or state law requirements regarding the confidentiality of education records that it may come to possess.

II. RELEASE OF INFORMATION: I consent to the use and disclosure of the Patient’s health information for purposes of treatment, payment and health care operations as described in the Notice of Privacy Practices.  I authorize and direct the Practice to release to government agencies, insurance carriers, managed care companies, or other entities who are or may be financially liable for the Patient’s medical care (and to authorized agents of such entities) all information needed to substantiate payment for this medical care and to permit representatives thereof to examine and request copies of records related to the Patient’s case and medical treatment.  I further authorize the Practice to release billing information to any healthcare provider involved in the Patient’s care.

I understand that the Practice has implemented security measures sufficient to protect the Patient’s electronic health information. Electronic health information is stored in a secure data center in encrypted format to prevent unauthorized individuals from viewing or accessing such data.  The Practice also utilizes password and authentication protections as additional safeguards where appropriate.

I authorize the Practice to use and disclose my protected health information (“PHI”) as permitted under the Health Insurance Portability and Accountability Act (“HIPAA”), other applicable law, and by the Practice’s Notice of Privacy Practices. I consent to the Practice accessing, storing and sharing my medical information electronically through one or more health information exchanges (“HIEs”) pursuant to applicable state and federal law. I understand that other healthcare providers within the HIE network will have access to my health information for purposes of treatment, payment and healthcare operations and that I may choose to direct the Practice not to share my health information with the HIE network by submitting to the Practice a signed copy of the Health Information Exchange Opt-Out form (available upon request).

III. ASSIGNMENT: I assign, transfer and set over to the Practice sufficient monies and/or benefits to which I am or may be entitled from government agencies, insurance carriers, or others who may be financially responsible for the Patient’s medical care to cover costs of the care and treatment rendered.

IV. PATIENT GUARANTEE OF PAYMENT: I accept that I am financially responsible for all services rendered on the Patient’s behalf for which a charge may be associated.  I accept personal responsibility for all co-payments, deductibles, and non-covered services, as dictated by my or the Patient’s insurance coverage (hereinafter, the “insurance plan”), plus any collection costs for amounts personally owed by me.  I acknowledge that services provided by the Practice may not be covered by the insurance plan for one or more reasons, including but not limited to exclusions under the insurance plan, exhaustion of benefits, the insurance plan’s designation of the Practice as an out-of-network provider, and/or my failure to provide the insurance card.  I understand that if I do not fulfill the requirements of the insurance plan, do not receive the requisite prior approval, if the authorization is denied or if the insurance plan refuses to pay the cost of the services for any other reason, I understand and agree that I am financially responsible for the cost of these services.

If the insurance plan sends me or the Patient money that is designated to pay for the services provided by the Practice, I agree to immediately send the check or an amount equal to the amount received by the insurance plan to the Practice.  I understand that all bills are to be paid immediately upon receipt.  I also understand that in the event my account is transferred to a collection agency due to my failure to pay for the services, that I will be responsible for any reasonable attorney’s fees and collection fees incurred by the Practice in collecting payment, in addition to the amount of the bill.

V. HIPAA ACKNOWLEDGEMENT: I acknowledge that I have reviewed and understand the Practice’s Notice of Privacy Practices containing a description of the uses and disclosures of my health information.  I further understand that the Practice may update its Notice of Privacy Practices at any time, and that I may receive an updated Notice of Privacy Practices by submitting a request in writing to the Practice or by accessing the most current Notice of Privacy Practices online at pmpediatriccare.com or pmpediatriccare.com/telemedicineforms.

VI. COMMUNICATIONS: I understand that the Practice may need to contact me regarding the healthcare services provided to the Patient.  I authorize the Practice to call the phone number I have provided and to leave voicemail messages with respect to the Patient’s clinical care, to facilitate treatment, payment and health care operations, and for quality improvement or educational purposes.  I consent to the Practice mailing materials incident to treatment, payment and health care operations to the address I have provided, such as billing statements and/or other materials containing PHI.  I consent to receive text messages and/or emails (generated through an automated system or otherwise) from or on behalf of the Practice for purposes of treatment, payment and health care operations, including, without limitation, quality improvement and patient satisfaction activities.  I understand that the Practice cannot guarantee the privacy, security or confidentiality of text messages or email communications sent or received.  I understand that I may opt-out of receiving automated emails or text messages at any time.

VII. AFFIRMATION: I affirm that I have read and fully understand this Consent to Treat, Guarantee of Payment, and Acknowledgement of Notice of Privacy Practices form and have been given the opportunity to ask questions and that all my questions have been answered to my satisfaction.