Terms & Conditions & Consent to Participate in Telemedicine Services CONSENT TO PARTICIPATE IN TELEMEDICINE SERVICES Purpose The purpose of this form is to obtain your consent to participate in a telemedicine health service provided by Summit Medical Group, Inc. dba St. Elizabeth Physicians (“SEP”). Nature of Telemedicine Health Services During the telemedicine health service: (a) details of your medical history, examinations, x-rays, and other tests may be discussed through the use of interactive video, audio, and telecommunications technology; (b) visual examination of you may take place; and (c) nonmedical technical personnel may be requested to enter the area where the telemedicine health service is being performed. No video, audio, and/or photo recordings will be taken of the encounter and you have the right to object to the video taping of a telemedicine health service. You will be informed if any additional personnel are to be present other than your provider and must give your verbal permission prior to the entry of the additional personnel. Security The electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. Firewalls, passwords, encryption, and audit trails are used to safeguard your information. In order to initiate a telemedicine health service you must access your MyChart account. Patients should use a smartphone or tablet that uses either the Apple or Android operating system with the most up to date version of the MyChart App. Do not attempt to use this service through the web browser (safari/Internet/chrome) on your phone. The current version of the MyChart App is 9.2.6 and it can be downloaded from the App Store or Google Play. Your device will need to be connected to a wifi broadband network or have a reliable cellular signal to be able to properly make the connection. Make sure that the sound and camera is enabled before starting the telemedicine health service. Like any video streaming service, be aware that if using a cellular connection, it will use a significant amount of wireless data per minute. Any costs associated with cellular data usage are solely your responsibility. Medical Information and Records All existing laws regarding privacy and security of your health information and copies of your medical records apply to telemedicine health services and the audio and video information transmitted and received as part of this service. SEP affords the same degree of confidentiality to medical information communicated during telemedicine health services as is given to medical information communicated to SEP through any other medium. You may have access to medical information resulting from the telemedicine consultation in accordance with applicable law. SEP will not be retaining or storing any identifiable images from the telemedicine health service. Notwithstanding the foregoing, should practices change regarding the dissemination, storage, or retention of an identifiable patient image or other information from the telemedicine health service, SEP shall comply with all federal and state law. Further, notwithstanding the foregoing, any dissemination of patient-identifiable images or information from this telemedicine interaction to researchers or other entities for purposes other than your treatment, payment for healthcare services you receive, and certain necessary administrative and operational activities supporting your care shall not occur without your express authorization. You acknowledge that you have been provided with SEP’s Notice of Privacy Practices. A copy of SEP’s Notice of Privacy Practices can be found here. Your Rights You may withhold or withdraw your consent to the telemedicine health service at any time before or during the consult without affecting the right to future care or treatment and without risking the loss or withdrawal of a Medicaid or any other benefit to which, if applicable, you may be entitled. You may also withdraw consent to extra personnel participating in the telemedicine health service. No video images or audio recordings will be retained or stored by SEP. In the alternative to a telemedicine health service, you may schedule an office visit with your provider. Risks As with any medical procedure, there are potential risks associated with the use of telemedicine health services. These risks include, but are not limited to: (a) in rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the provider; (b) delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment; (c) in rare instances, security protocols could fail, causing a breach of privacy of personal health information; or (d) loss of information due to technical failures. By signing below you agree that: (a) you have received an explanation of how the video and audio technology will be used to conduct the telemedicine health service, and you understand there are limitations to technology and the process of telemedicine, including the potential for incomplete exchange or loss of information; (b) you understand the risks associated with a telemedicine health service and agree to hold harmless SEP for information lost due to technical failures; (c) you understand the information provided on telemedicine and voluntarily and freely agree and give your consent to take part in the telemedicine health service and to any related evaluation, assessment, and diagnosis as the provider deems appropriate for your current medical condition and the consultation; (d) you understand that the provider determines whether or not the condition being diagnosed and/or treated is appropriate for a telemedicine health service; (e) you understand that a variety of alternative methods of medical care may be available to you and that you may choose one or more of these at any time and that your provider has explained the alternatives to your satisfaction; (f) you understand that it is your responsibility to make arrangements for follow-up care; (g) you have discussed the telemedicine health services with your provider or such assistants as may be designated and all of your questions have been answered to your satisfaction; and (h) you are currently present in the same state as the provider’s office. Telemedicine Services TERMS AND CONDITIONS OF USE Introduction Welcome to St. Elizabeth Physicians ("SEP") Telemedicine Health Services, an innovative and convenient way for you to receive care from a SEP provider for selected and non-urgent conditions. These Terms and Conditions are between you and SEP. "SEP", "we", and "us" means St. Elizabeth Physicians. "You" means the person who clicks electronically signs below and uses the telemedicine service. READ THESE TERMS AND CONDITIONS CAREFULLY. BY SIGNING BELOW OR OTHERWISE USING THE APPLICABLE TELEMEDICINE SERVICE, YOU ARE (A) ACKNOWLEDGING THAT YOU HAVE READ AND UNDERSTAND THESE TERMS AND CONDITIONS; (B) AGREEING TO BE BOUND BY THESE TERMS AND CONDITIONS. IF YOU DO NOT AGREE TO BE BOUND BY THESE TERMS AND CONDITIONS, DO NOT SIGN AND YOU WILL NOT BE PERMITTED TO USE THE APPLICABLE TELEMEDICINE SERVICE. Electronic communication cannot substitute for an in-person medical evaluation in which a physician or other qualified health provider takes a history from a patient, conducts a physical examination, and orders and interprets the appropriate diagnostic tests. When you visit your provider in-person, he or she has a chance to see, hear, feel, and otherwise perceive health issues that you may not even have noticed or thought important to mention. However, in a telemedicine health service your provider perceives only what you communicate. If you do not describe an important symptom whether because you didn't know it was important, you were not good at communicating it, or for some other reason, your provider may not be able to provide advice. Accordingly, providers will offer telemedicine treatment via this portal only for non-urgent symptoms. At any time during the telemedicine health service, a provider may terminate the telemedicine health service and advise you to seek treatment from an in-person provider visit or, if it appears to the provider that the symptoms described are emergent, to seek care at the closest emergency room. If you experience symptoms like shortness of breath, chest pain, dizziness, weakness, confusion, high fever, sudden or major bleeding, severe rashes or hives, severe allergic reactions, or any other symptoms that might suggest a serious condition, CALL YOUR DOCTOR'S OFFICE, VISIT THE NEAREST HOSPITAL EMERGENCY DEPARTMENT, OR DIAL 911 IMMEDIATELY. eVisits eVisits are designed for adults age 18 years old and over who are current patients of St. Elizabeth Physicians. eVisits can be used only for non-urgent symptoms. To be eligible you must have been seen (A) within the last 12 months if you are over 40 years old or (B) within the past 24 months if 40 or younger. This ensures that your provider will have current information about your health status when evaluating your concerns. Absent unusual circumstances, messages will be answered within four to six hours; however, this response time cannot be guaranteed. Messages submitted after hours will be answered the following day. Controlled substances will not be prescribed through eVisits. The cost is $35 and while it is currently not billable to most insurance companies, it is reimbursable through HSA plans. Once you have accepted these Terms and Conditions, you are presented with a screen where you enter your credit card information. Enter all of the information requested. Your credit card information will be re-displayed for your review. Your credit card will not be charged until the entire eVisit process has been completed. You are prohibited from using an eVisit if you are outside the state in which your provider is located. Our health care providers are licensed in the jurisdictions in which their respective clinics are located. Simply sign on through your MyChart account and select “Get Medical Advice” from the buttons on the left. From there, select eVisits. From this screen you will be able to review the common, non-urgent conditions that are currently often treatable through an eVisit. If you have a concern that fits into one of these areas, you may select it, and proceed to provide the requested information on your concern. The completion of an eVisit does not guarantee that a prescription will be dispensed if it is not deemed an appropriate treatment by your provider. Once you click “Submit”, the information is presented directly to an SEP provider, your Primary Care Provider in most cases, along with your complete electronic medical record, for review. In most cases, the provider will be able to address your concerns and complete your treatment plan and recommendations online. If the provider reviews your symptoms and chart and feels that it would be best for your care to be seen for a traditional office visit, you will not be charged for the eVisit. Do not send requests on behalf of someone else or about someone else's health. Your eVisit messages to your provider and his or her responses to your messages become part of your medical record. This information is generally held confidential but may be used and disclosed by us in accordance with our Notice of Privacy Practices (“Notice”). Our Notice can be accessed here. Video Visits Video Visits are designed for current patients of St Elizabeth Physicians age two years old and older. Video Visits can be used only for non-urgent symptoms. To be eligible you must have been seen (a) within the last 12 months if you are over 40 years old; or (b) seen within the past 24 months if 40 or younger. This ensures that your provider will have current information about your health status when evaluating your concerns. Video Visits are scheduled through your provider's practice. While Video Visits are currently not billable to most insurance companies, they are reimbursable through HSA plans. You will not be prompted to pay for this Video Visit prior to the Video Visit start. Since you are financially responsible for this Video Visit, you will receive a billing statement from SEP and payment is expected in accordance with SEP's standard payment terms. The cost will also appear in your MyChart account and is able to be paid directly through the MyChart app. You are financially responsible for this Video Visit. Once you have accepted these Terms and Conditions, you are presented with an Informed Consent screen. Please carefully review the Informed Consent in detail. If you have any questions, contact your provider. You are prohibited from using a Video Visit if you are presently outside the state in which your provider’s office is located. Our health care providers are licensed in the jurisdictions in which their respective clinics are located. Once you provide Informed Consent, the Video Visit will begin and your complete electronic medical record will be available for the provider to review. In most cases, the provider will be able to address your concerns and complete your treatment plan and recommendations via the Video Visit. If the provider reviews your symptoms and chart and feels that it would be best for your care to be seen for a traditional office visit, the Video Visit will cease, you will not be billed and you will be instructed regarding next steps. Conclusion AGAIN, IF YOU HAVE AN IMMEDIATE NEED, CALL YOUR PROVIDER'S OFFICE. IF THIS IS AN EMERGENCY, CALL 911 OR GO TO THE NEAREST URGENT CARE OR EMERGENCY ROOM. By signing below or otherwise consummating a telemedicine service, you acknowledge that any previous consents given by you to SEP will apply to a telemedicine health service also, including, but not limited to, consents to share your information as necessary to care for you, and consents to bill your insurance company and release your information to your insurer as necessary for our bills to be paid. BY SIGNING BELOW OR OTHERWISE USING A TELEMEDICINE HEALTH SERVICE, YOU ARE (A) ACKNOWLEDGING THAT YOU HAVE READ AND UNDERSTAND THESE TERMS AND CONDITIONS; (B) AGREEING TO BE BOUND BY THESE TERMS AND CONDITIONS. IF YOU DO NOT AGREE TO BE BOUND BY THESE TERMS AND CONDITIONS, DO NOT SIGN AND YOU ARE NOT PERMITTED TO USE THE APPLICABLE TELEMEDICINE HEALTH SERVICE.