Last updated 2024-11-01
I understand and agree with the following and agree to receive health care services via telehealth:I understand that telehealth/telemedicine requires the transmission of personal health information via the internet and/or other electronic communication methods, for use in diagnosis, therapy, follow-up, and/or education. The personal health information transmitted may include but not be limited to:
• Progress reports, assessments, or other intervention-related documents;
• Bio-physiological data; and
• Videos, images, text messages, audio, and data in digital format.
I understand that healthcare providers involved in telehealth/telemedicine may include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants, and other healthcare providers who are a part of my clinical care team. In addition, my family members, caregivers, or other legal representatives or guardians may participate in the telehealth/telemedicine service, and I agree to share my personal health information with them as needed.
I understand that individuals other than my clinical care team or consulting providers may also be present and have access to my information while in the process of operating, maintaining, or repairing the computer, video, or audio equipment used. These persons will adhere to applicable privacy and security policies and legal requirements.
I understand that the laws that protect privacy and the confidentiality of personal health information also apply to telehealth/telemedicine, and that no information obtained in the use of telehealth/telemedicine that identifies me will be disclosed to anyone without my consent except for the purposes of treatment, education, billing, and/or healthcare operations, unless an exception to confidentiality applies (i.e., mandatory reporting of child, elder, or vulnerable adult abuse, posing a danger to self or others, or my raising mental/emotional health as an issue in a legal proceeding).
Expected Benefits:
There are many benefits that I may expect from receiving services via telehealth/telemedicine, including improved access to medical care from my home or another convenient location; efficient evaluation and management of condition; and access to specialists.
Potential Risks
As in any medicine setting, there are potential risks associated with receiving services via telehealth/telemedicine, including but not limited to: insufficient transmission of information (e.g., poor picture or sound quality) to allow to appropriate medical decision-making by the provider; delays in evaluation and/or treatment due to technical failures; and lack of access to complete medical records. I understand that the health information that I provide at the time of my telehealth/telemedicine service may be the only source of health information used by the medical professionals during the course of my evaluation and treatment at the time of my telehealth/telemedicine visit, and that such professionals may not have access to my full medical record or information held by Rise Sleep Medical Group, P.A., and I agree to provide full and accurate information relevant to the telehealth/telemedicine encounter to my provider. I understand that failure to provide complete and accurate information regarding my health to my provider may result in misdiagnosis or ineffective treatment.
I understand that, as with any internet-based communication, telehealth/telemedicine involves a risk of security breach. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data, and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
I understand that telehealth/telemedicine sessions may not always be possible. Disruptions of signals or problems with the internet’s infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, and/or audio interference) that prevent effective interaction between consulting clinician(s), participant, patient, or care team.
I hereby release and hold harmless Rise Sleep Medical Group, P.A., its business associates, and all members of my care team from any loss of data or information that may be due to technical failures associated with the telehealth/telemedicine service.
I understand that I will be given information about test(s), treatments(s) and procedures(s), as applicable, including the benefits, risks, possible problems or complications, and alternate choices for my medical care through the telehealth/telemedicine visit.
I understand that a variety of alternative methods of health care, including in-person care, may be available to me, and that I may choose one or more of these at any time. My provider has explained the alternatives to my satisfaction.
I understand that I have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time. I understand that if I withdraw my consent for telehealth/telemedicine, it will not affect any future services or care benefits to which I am entitled, but no further telehealth/telemedicine services will be provided.
I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth/telemedicine services are not appropriate and that a higher level of care is required.
I understand that I have the right to inspect all information obtained and recorded in the course of a telehealth/telemedicine interaction, and that I may receive copies of this information for a reasonable fee.
I understand that while I may anticipate benefits from the use of telehealth/telemedicine in my care, but that no results can be guaranteed or assured.
I hereby consent to the use of telehealth/telemedicine in the provision of care, under the terms and conditions set forth above.
I certify that I am the patient and am 18 years of age or older, or that I am the legal representative of the patient, or that I am otherwise legally authorized to provide consent. I have carefully read and understand the above statements. I have had all of my questions answered. I understand that this informed consent will become a part of my medical record.
I consent to mental health evaluation and/or treatment at Rise Sleep Medical Group, P.A. (and its affiliates) (“Practice”) by mental health staff, which may include psychiatrists, licensed clinical social workers, licensed marriage and family therapists, psychiatric nurse practitioners, physicians assistants, or other mental healthcare practitioners supervised by psychiatrists, licensed clinical social workers, licensed marriage and family therapists, or other professionally licensed staff. I also authorize such treatment or diagnostic studies as, in the judgment of mental health staff, may reasonably be necessary to preserve and protect my health and wellbeing. No guarantee is being made to me regarding results of treatment. If appropriate, I understand that I may be prescribed prescription medication. I understand that there are inherent risks in pharmacologic treatment and that there may be adverse side effects and results that are not anticipated. I consent to be treated with knowledge of possible risks and understand that I will be informed of possible adverse effects when applicable.Communications between a psychiatrist or other professionally licensed mental health staff and a patient are confidential. Confidentiality prohibits the disclosure of information related to the mental health staff-patient relationship without consent from the patient. I have completed the Practice’s Authorization for Use/Disclosure of Protected Health Information, and have received and reviewed the Practice’s Notice of Privacy Practices.I understand that I can withdraw this consent for mental health treatment at any time by providing written notice to Practice staff.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Rise Sleep Medical Group, P.A. and its employees are dedicated to maintaining the privacy of your personal health information (“PHI”), as required by applicable federal and state laws. We are required by law to maintain the privacy and security of your PHI. These laws require us to provide you with this Notice of Privacy Practices, and to inform you of your rights and our obligations concerning Protected Health Information, or PHI, which is information that identifies you and that relates to your physical or mental health condition. We are required to follow the privacy practices described below while this Notice is in effect. We will let you know promptly if a breach occurs that many have compromised the privacy or security of your information. We will not use or share your information other than as described here unless you tell us we can in writing, and you may change your mind at any time. Let us know in writing if you change your mind.
A. Permitted Disclosures of PHI. We may disclose your PHI for the following reasons:
1. Treatment. We may disclose your PHI to a physician or other healthcare provider providing treatment to you. For example, we may disclose medical information about you to physicians, nurses, technicians or personnel who are involved with the administration of your care.
2. Payment. We may disclose your PHI to bill and collect payment for the services we provide to you. For example, we may send a bill to you or to a third-party payor for the rendering of services by us. The bill may contain information that identifies you, your diagnosis and procedures and supplies used. We may need to disclose this information to insurance companies to establish insurance eligibility benefits for you. We may also provide your PHI to our business associates, such as billing companies, claims processing companies and others that process our healthcare claims.
3. Healthcare Operations. We may disclose your PHI in connection with our healthcare operations. Healthcare operations include quality assessment activities, reviewing the competence or qualifications of healthcare professionals, evaluating provider performance, and other business operations. For example, we may use your PHI to evaluate the performance of the healthcare services you received. We may also provide your PHI to accountants, attorneys, consultants and others to make sure we comply with the laws that govern us.
4. Emergency Treatment. We may disclose your PHI if you require emergency treatment or are unable to communicate with us.
5. Family and Friends. We may disclose your PHI to a family member, close friend or any other person who you identify as being involved with your care or payment for care, unless you have objected or shared your preference with us in writing that we not share your information with family or close friends.
6. Required by Law. We may disclose your PHI for law enforcement purposes and as required by state or federal law. For example, the law may require us to report instances of abuse, neglect or domestic violence; to report certain injuries such as gunshot wounds; or to disclose PHI to assist law enforcement in locating a suspect, fugitive, material witness or missing person. We will inform you or your representative if we disclose your PHI because we believe you are a victim of abuse, neglect or domestic violence, unless we determine that informing you or your representative would place you at risk. In addition, we must provide PHI to comply with an order in a legal or administrative proceeding. Finally, we may be required to provide PHI in response to a subpoena discovery request or other lawful process, but only if efforts have been made, by us or the requesting party, to contact you about the request or to obtain an order to protect the requested PHI.
7. Serious Threat to Health or Safety. We may disclose your PHI if we believe it is necessary to avoid a serious threat to the health and safety of you or the public.
8. Public Health. We may disclose your PHI to public health or other authorities charged with preventing or controlling disease, injury or disability, or charged with collecting public health data.
9. Health Oversight Activities. We may disclose your PHI to a health oversight agency for activities authorized by law. These activities include audits; civil, administrative or criminal investigations or proceedings; inspections; licensure or disciplinary actions; or other activities necessary for oversight of the health care system, government programs and compliance with civil rights laws.
10. Research. We may disclose your PHI for certain research purposes, but only if we have protections and protocols in place to ensure the privacy of your PHI.
11. Workers’ Compensation. We may disclose your PHI to comply with laws relating to workers’ compensation or other similar programs.
12. Specialized Government Activities. If you are active military or a veteran, we may disclose your PHI as required by military command authorities. We may also be required to disclose PHI to authorized federal officials for the conduct of intelligence or other national security activities.
B. Disclosures Requiring Written Authorization.
1. Not Otherwise Permitted. In any other situation not described in Section A above, we may not disclose your PHI without your written authorization.
2. Psychotherapy Notes. We must receive your written authorization to disclose psychotherapy notes, except for certain treatment, payment or health care operations activities.
3. Marketing and Sale of PHI. We must receive your written authorization for any disclosure of PHI for marketing purposes or for any disclosure which is a sale of PHI.
C. Your Rights.
1. Right to Receive a Paper or Electronic Copy of This Notice. You have the right to receive a paper or electronic copy of this Notice upon request.
2. Right to Access PHI. You have the right to inspect and copy your PHI for as long as we maintain your medical record. You have the right to receive an electronic or paper copy of your medical record or other PHI we have about you. You must make a written request for access to the Compliance Officer at the address listed at the end of this Notice. We may charge you a reasonable fee for the processing of your request and the copying of your medical record pursuant to applicable state law. In certain circumstances we may deny your request to access your PHI, and you may request that we reconsider our denial. Depending on the reason for the denial, another licensed health care professional chosen by us may review your request and the denial. We will provide a written explanation of any denial.
3. Right to Request Restrictions. You have the right to request a restriction on the use or disclosure of your PHI for the purpose of treatment, payment or health care operations, except for in the case of an emergency. You also have the right to request a restriction on the information we disclose to a family member or friend who is involved with your care or the payment of your care. However, we are not legally required to agree to such a restriction and many deny your request.
4. Right to Restrict Disclosure for Services Paid by You in Full. You have the right to restrict the disclosure of your PHI to a health plan if the PHI pertains to health care services for which you paid in full directly to us. We will not share your PHI with health insurers if you have paid out-of-pocket in full and you have asked us not to share such information with your health insurer.
5. Right to Request Amendment. You have the right to request that we amend your PHI if you believe it is incorrect or incomplete, for as long as we maintain your medical record. We may deny your request to amend if (a) we did not create the PHI, (b) is not information that we maintain, (c) is not information that you are permitted to inspect or copy (such as psychotherapy notes), or (d) we determine that the PHI is accurate and complete. We will provide a written explanation of any denial.
6. Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures of PHI made by us (other than those made for treatment, payment or health care operations purposes) during the 6 years prior to the date of your request. You must make a written request for an accounting, specifying the time period for the accounting, to the Compliance Officer at the address listed at the end of this Notice. We will provide one accounting a year for free, but we will charge a reasonable fee if you request another accounting within 12 months.
7. Right to Confidential Communications. You have the right to request that we communicate with you about your PHI by certain means or at certain locations. For example, you may specify that we call you only at your home phone number, and not at your work number. You must make a written request, specifying how and where we may contact you, to the Compliance Officer at the address listed at the end of this Notice.
D. Changes to this Notice. We reserve the right to change this Notice at any time in accordance with applicable law. Changes will apply to all information we have about you. The new notice will be available upon request and on our website. Prior to any substantial changes related to the use or disclosure of your PHI or your rights or our duties, we will distribute a revised Notice to you.
E. Acknowledgment of Receipt of Notice. We will ask you to sign an acknowledgment that you received this Notice.
F. Direct Contact with You. We may use your PHI to contact you to remind you that you have an appointment, or to inform you about treatment alternatives or other health-related benefits and services that may be of interest to you.
G. Questions and Complaints. If you would like more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made regarding the use, disclosure, or access to you PHI, you have the right to file a complaint to us by contacting the Compliance Officer at the address and phone number at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file such a complaint upon request. We support your right to the privacy of your PHI. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Please direct any of your questions or complaints to: Rise Sleep Medical Group, P.A.
2332 Galiano Street, 2nd Floor
Coral Gables, Florida 33134-5402
United States
415-840-8911
The following is a statement of our financial policy, which we require that you read and agree to prior to any treatment.
Financial responsibility. Please understand that payment of your bill is considered part of our relationship. Fees are payable when services are rendered. We accept credit cards and pre-approved insurance for which we are a contracted provider, if applicable.
Your responsibility to understand your insurance benefits. It is your responsibility to know your own insurance benefits, including whether we are a contracted provider with your insurance company, your covered benefits and any exclusions in your insurance policy, and any pre-authorization requirements of your insurance company.
We will attempt to confirm insurance coverage. We will attempt to confirm your insurance coverage prior to your treatment. It is your responsibility to provide current and accurate insurance information, including any updates or changes in coverage. Should you fail to provide this information, you will be financially responsible for payment in full for all services. In the event we provide any estimate of your out-of-pocket costs, such amount is only an estimate and not a guarantee of any final amount that you may be required to pay.
We bill insurance first, then you. If we have a contract with your insurance company we will bill your insurance company first, less any copayment(s) or deductible(s), and then bill you for any amount determined to be your responsibility. This process generally takes 45-60 days from the time the claim is received by the insurance company.
You are responsible if we are not contracted with your insurance company or if you insurance company does not cover our services for any reason. If we do not contract with your insurance company or if your insurance company does not cover our services for any reason (including, without limitation, errors in the information provided to us, expired coverage, exhaustion of benefits), you will be expected to pay for all services rendered at the end of your visit. We will provide you with a statement that you can submit to your insurance company for reimbursement. You may have choices for obtaining similar services from in-network providers that may be covered by your health insurance policy or health plan. You can contact your health insurance company to find an in-network provider or facility.
Proof of payment and photo ID are required for all patients. We may ask to make a copy of your ID and insurance card for our records. Providing a copy of your insurance card does not confirm that your coverage is effective or that the services rendered will be covered by your insurance company.
Out-of-network benefits may have additional charges. Please understand some insurance coverages have Out-of-Network benefits that have co-insurance charges, higher co-payments and limited annual benefits. If you receive services are part of an Out-of-Network benefit, your portion of financial responsibility may be higher than the In- Network rate.
By pursuing services from Rise Sleep Medical Group, P.A., you agree to and understand the financial policies contained above, and acknowledge clear understanding of your financial responsibility. You understand that if your insurance company denies coverage and/or payment for services provided to you, you assume financial responsibility and will pay all such charges in full
Agreement to the following is necessary prior to engaging in electronic communications with Rise Sleep Medical Group, P.A. (the “Practice”).
Electronic Communication Policy“Electronic communication” means unsecured e-mail or text messaging with patients outside of a secured patient portal or other HIPAA-protected mode of communication.
The following policies and limitations apply to the use of the Practice’s electronic communication:
1. Electronic communication is not for emergency purposes. If you are having an emergency, dial 911 or go to your local hospital.
2. Correspondence via electronic communication is supplemental to physician/patient encounters. The Practice will not provide electronic communication-based diagnosis and treatment.
3. Sensitive subject matter, such as HIV/AIDS, STDs, mental health, behavioral health, drug treatment, or genetic testing information, cannot be discussed through electronic communication.
4. Communications sent via electronic communication must be courteous, respectful, appropriate, fact-based and truthful.
5. The Practice will apply reasonable safeguards when using electronic communications to protect the privacy and security of patient information, but there are risks to communicating via unencrypted methods, including the risk of disclosure of information to unintended recipients.
Conditions of Participation
Electronic communication with the Practice is restricted to communication with the patient. This type of communication is optional, and we reserve the right to suspend or terminate it at any time. If the Practice suspends access, you will still have access to copies of your medical record and other health information upon request.The patient acknowledges that he/she agrees to comply with the Practice’s Electronic Communication Policy outlined above.
The patient also acknowledges and understands the risks of using unencrypted electronic communications, including unintentional disclosure to third parties.
In an effort to focus more attention on you, our patient, Rise Sleep Medical Group, P.A. (the “Practice”) may use software to transcribe your appointment or build summaries of your visit, including any recommended medications, diagnostics, and other treatments. This frees your health care provider from typing notes during and after the appointment, allowing your health care provider to provide more time and attention to you and your needs. We are required by state law to seek and obtain your permission before providing such services.
This service consists of live audio and video recording of your appointment and other conversations during an appointment. Upon your consent, and unless notified otherwise, your video or phone session and audio and video data will be transmitted to the transcription service. We only use the relevant portions of the audio and video data for the purposes of transcribing your appointment and not for any other purpose.
We and any transcription partners we may use take your privacy and data security very seriously, and we have implemented measures designed to secure the information.
We appreciate your understanding and support as medical transcription helps us provide better care to you. If at any point you or any visitors with you wish to withdraw your consent to this service, simply notify our team, and it will be turned off immediately.
You (and any family or close friend participating in your telehealth sessions at your invitation) expressly consent to the Practice and our transcription partner to record audio and video of your visit, transcribe and document your appointment.
Please refer to our Privacy Policy for information on how we collect, use and disclose information from our users. You acknowledge and agree that your use of the Services is subject to our Privacy Policy.
For the usage of the Rise Science app or digital products, website, blog or communications, please refer to Rise Science's Terms of Service.
We may modify the Terms at any time, in our sole discretion. If we do so, we’ll let you know either by posting the modified Terms on the Site or through other communications. It’s important that you review the Terms whenever we modify them because if you continue to use the Services after we have posted modified Terms on the Site, you are indicating to us that you agree to be bound by the modified Terms. If you don’t agree to be bound by the modified Terms, then you may not use the Services anymore. Because our Services are evolving over time we may change or discontinue all or any part of the Services, at any time and without notice, at our sole discretion.
Unless you opt out of arbitration within 30 days of the date you first agree to these terms by following the opt-out procedure specified in the “Arbitration” section below, and except for certain types of disputes described in the “Arbitration“ section below, you agree that disputes between you and Rise will be resolved by binding, individual arbitration and you are waiving your right to a trial by jury or to participate as a plaintiff or class member in any purported class action or representative proceeding.
