Terms and Conditions including Informed Consent to Telehealth Services and JASE Medical, LLC Policies
Last updated: March, 2022
This describes JASE Medical LLC‘s Telehealth treatment and payment policies and includes:
- Your consent to receive medical treatment from contracted professional health care providers (and your other rights and responsibilities);
- Your agreement to receive services using telehealth technology; and Your agreement to pay in full any charges that are your responsibility.
- Your agreement to use the prescribed medications ONLY in the event of an emergency and under the guidance of a qualified healthcare professional.
If I am signing on behalf of an incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept full financial responsibility for services rendered.
JASE Medical Telehealth Portal
By using the JASE Medical telehealth portal, I agree to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive digital communications. During my visit, my JASE Medical contracted provider and I will be able to communicatewith each other from remote locations.
I understand and agree that:
- I will not be in the same location or room as my medical provider.
- My JASE Medical contracted provider is licensed in the state in which I am receiving services.
- I will report my location accurately during registration.
Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to my JASE Medical’s contracted provider’s office; (ii) more efficient medical evaluation and management; and (iii) during the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location.
Potential risks of telehealth include: (i) limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my medical provider in diagnosis and treatment; (ii) my provider’s inability to conduct a hands-on physical examination of me and my condition; and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures.
I will not hold JASE Medical or its contracted health care providers responsible for lost information due to technological failures.
I consent to the use of potential non-secure forms of communication that may contain sensitive health data.
I further understand that my Provider’s advice, recommendations, and or decisions may be based on factors not within his/her control, including incomplete or inaccurate data provided by me.
I understand that my provider relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.
I may discuss these risks and benefits with the provider and will be given an opportunity to ask questions about telehealth services.
I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to present or future treatment by JASE Medical, LLC or its contracted health care providers.
I understand that the level of care provided by my JASE Medical contracted provider is to be the same level of care that is available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to the nearest medical center, hospital emergency department or other appropriate health care provider.
In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
I consent to, understand, and agree that: I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives.
Contracted health care providers will provide care consistent with the prevailing standards of medical practice but make no assurances or guarantees as to the results of treatment.
My JASE Medical contracted provider will not prescribe any controlled substances including opioids to me during a telehealth visit.
Emergency Use of Antibiotics
I agree, if antibiotics or other medications are prescribed as a result of this TELEHEALTH VISIT, that I will use said antibiotics or medications ONLY in an emergency situation, after first seeking to secure the assistance of a qualified health care professional and determining that qualified health care assistance is not readily available.
Further, I will promptly inform the TELEHEALTH PROFESSIONAL of any significant change in my health.
I understand and agree that these antibiotics and other medications should be stored properly and kept securely out of the reach or access of children.
Any questions relating to the use of the antibiotics or medications should be directed to the TELEHEALTH PROFESSIONAL.
I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to JASE Medical’s standard policies regarding request and receipt of medical records and applicable law.
The laws of the state in which I am located will apply to my receipt of telehealth services.
JASE Medical Notice of Privacy Practices
JASE Medical will protect the privacy of my health information and will not use or disclose it except as permitted by law. JASE Medical’s privacy policies are more fully described in the Privacy Notice, which is available for review and download here: https://JASEmedical.com/privacy-practices.
By signing this Consent, I acknowledge receipt of the Privacy Notice and consent to JASE Medical’s use and disclosure of my health information in accordance with its terms.
I understand that all existing confidentiality protections that apply to in-person treatment apply also to telehealth services.
I hereby release and agree to hold harmless the Physician and all Physician assistants and staff from any liability, injury, damages, loss, accidents, delay or irregularity related to or arising out of my storage or use of the antibiotics and other medicines prescribed or issued pursuant to my telehealth encounter with Physician and any subsequent prescriptions and treatment.
Consent for the Treatment of a Minor or Ward
If acting as the parent or legal guardian of a minor child or legally appointed ward, I hereby do voluntarily consent for the authorized health care providers of Jase Medical, LLC (“Jase Medical”) to provide medical care as they deem necessary to my minor or legally appointed ward. The authorized health care providers are independent contractors of Jase Medical and all decisions made by the authorized health care provider will be based on his or her independent professional medical judgement. I understand that such medical care may include, but is not limited to, a telehealth encounter and prescription of medications, and any follow-up medical services that may be recommend by the health care provider.
I understand that I am making this Consent in advance of any medical examinations or treatment. This Consent shall apply to all services provided from the date signed below until otherwise revoked in writing by providing written notice to Jase Medical. I understand that a revocation of this Consent shall not apply to services provided prior to the revocation of this Consent.
I release Jase Medical and all of its officers, agents, employees, contractors, attorneys, directors, insurers, affiliates, related entities, successors, heirs, and assigns of any and all liability for acting in reliance on this Consent with the exception of clear medical negligence. I agree to assume financial responsibility for all services provided to my minor or legally appointed ward by Jase Medical and/or its authorized health care providers.
I acknowledge, understand and agree that:
- I will pay at the time of service.
- By providing my credit card information and receiving telehealth services, I (i) authorize JASE Medical to charge my credit card for any and all unpaid amounts that JASE Medical determines are my responsibility, and (ii) agree to pay all amounts charged pursuant to this consent and authorization in accordance with the issuing bank cardholder agreement.
- I agree that JASE Medical may charge my credit card for such amounts at the end of my telehealth visit or at a later date.
- I will be billed for all unpaid balances deemed by JASE Medical to be my responsibility and agree to pay such amounts in full.
- Delinquent accounts may be turned over to a collection agency at which time I am responsible for a $40 collections charge and all associated legal fees in addition to the amount owed.
- JASE Medical reserves the right to deny non-emergency services if my account is delinquent.
I understand that I may access and print a copy of these Terms and Conditions including Informed Consent to Telehealth Services by clicking here: https://jasemedical.com/terms-and-conditions
Disclosure of Conflict of Interest
I acknowledge that JASE Medical and its relevant physician-owners have disclosed to me the existence of a potential or actual conflict of interest, on the part of the physician-owner, arising out of the physician-owner’s economic and ownership interest in JASE Medical. I understand that this conflict of interest may compromise the independent professional judgment and recommendations of the physician-owner as the same relate to me, my treatment, and the issuing of any prescriptions on my behalf.
NOTICE OF PRIVACY PRACTICES
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.
We, the Physician Owner and JASE Medical are required by law to maintain the privacy of your protected health information, to notify you of our legal duties and privacy practices with respect to your health information, and to notify affected individuals following a breach of unsecured health information. This Notice summarizes our duties and your rights concerning your information. Our duties and your rights are set forth more fully in 45 CFR Part 164.
We are required to abide by the terms of our Notice that is currently in effect.
1. Uses And Disclosures We May Make Without Written Authorization.
We may use or disclose your health information for certain purposes without your written authorization, including the following:
- Treatment. We may use or disclose your information for purposes of treating you. For example, we may disclose your information to another health care provider so they may treat you; to provide appointment reminders; or to provide information about treatment alternatives or services we offer.
- Payment. We may use or disclose your information to obtain payment for services provided to you. For example, we may disclose information to your health insurance company or other payers to obtain payment for treatment.
- Healthcare Operations. We may use or disclose your information for certain activities that are necessary to operate our practice and ensure that our patients receive quality care. For example, we may use the information to train or review the performance of our staff or make decisions affecting the practice.
- Other Uses or Disclosures. We may also use or disclose your information for certain other purposes allowed by 45 CFR § 164.512 or other applicable laws and regulations, including the following:
- To avoid a serious threat to your health or safety or the health or safety of others.
- As required by state or federal law such as reporting abuse, neglect, or certain other events.
- As allowed by workers compensation laws for use in workers compensation proceedings.
- For certain public health activities such as reporting certain diseases.
- For certain public health oversight activities such as audits, investigations, or licensure actions.
- In response to a court order, warrant, or subpoena in judicial or administrative proceedings.
- For certain specialized government functions such as the military or correctional institutions.
- For research purposes, if certain conditions are satisfied.
- In response to certain requests by law enforcement to locate a fugitive, victim or witness, or to report deaths or certain crimes.
- To coroners, funeral directors, or organ procurement organizations as necessary to allow them to carry out their duties.
2. Disclosures We May Make Unless You Object.
Unless you instruct us otherwise, we may disclose your information as described below.
To a member of your family, relative, friend, or another person who is involved in your healthcare or payment for your healthcare. We will limit the disclosure to the information relevant to that person’s involvement in your healthcare or payment.
We participate in one or more Health Information Exchanges (HIE) which allows disclosure of your electronic health record via electronic transfer to other facilities and providers for your treatment purposes. Your health information and basic identifying information regarding your visits to our facilities may be shared with the HIEs for the purposes of diagnosis and treatment. This includes health information for your continuing care, as well as care you may seek at other locations. Other providers participating in these HIEs may access this information as part of your treatment.
3. Uses and Disclosures with Your Written Authorization.
Other uses and disclosures not described in this Notice will be made only with your written authorization, including most uses or disclosures of psychotherapy notes; for most marketing purposes. You may revoke your authorization by submitting a written notice to the Privacy Contact identified below. The revocation will not be effective to the extent we have already taken action in reliance on the authorization.
4. Your Rights Concerning Your Protected Health Information.
You have the following rights concerning your health information. To exercise any of these rights, you must submit a written request to the Privacy Officer identified below.
- You may request additional restrictions on the use or disclosure of information for treatment, payment or healthcare operations. We are not required to agree to the requested restriction except in the limited situation in which you or someone on your behalf pays for an item or service, and you request that information concerning such item or service not be disclosed to a health insurer.
- We normally contact you by telephone, mail at your home address and possibly by e-mail if you have given your email address. You may request that we contact you by alternative means or at alternative locations. We will accommodate reasonable requests.
- You may inspect and obtain a copy of records that are used to make decisions about your care or payment for your care, including an electronic copy. We may charge you a reasonable cost-based fee for providing the records. We may deny your request under limited circumstances, e.g., if we determine that disclosure may result in harm to you or others.
- You may request that your protected health information be amended. We may deny your request for certain reasons, e.g., if we did not create the record of if we determine that the record is accurate and complete.
- You may receive an accounting of certain disclosures we have made of your protected health information. You may receive the first accounting within a 12-month period free of charge. We may charge a reasonable cost-based fee for all subsequent requests during that 12-month period.
- You may obtain a paper copy of this Notice upon request. You have this right even if you have agreed to receive the Notice electronically.
5. Changes To This Notice.
We reserve the right to change the terms of this Notice at any time, and to make the new Notice effective for all protected health information that we maintain. If we materially change our privacy practices, we will post a copy of the current Notice in our reception area and on our website. You may obtain a copy of the operative Notice from our receptionist or Privacy Officer.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by notifying our Privacy Officer. All complaints must be in writing. We will not retaliate against you for filing a complaint.
7. Contact Information.
If you have any questions about this Notice, or if you want to object to or complain about any use or disclosure or exercise any right as explained above, please contact:
Privacy Officer: John Baird
Address: 2825 E. Cottonwood Parkway, Suite 500, Salt Lake City, Utah 84121
Effective Date. This Notice is effective June 1, 2021.