HER SMART CHOICE
DBA, CATHEDRAL MEDICAL INC


Telemedicine/Telehealth Consent Form:

‍By signing this form, I understand and agree with the following:Telehealth/Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists and/or subspecialists, nurse practitioners, registered nurses, medical assistants and other healthcare providers who are part of my clinical care team. In addition to myself and the members of my clinical care team, my family members, caregivers, or other legal representatives or guardians may join and participate in the telehealth/telemedicine service, and I agree to share my personal information with such family members, caregivers, legal representatives or guardians. The information may be used for diagnosis, therapy, follow-up and/or education.

Telehealth/Telemedicine requires transmission, via Internet or tele-communication device, of health information, which may include:Progress reports, assessments, or other intervention-related documents Bio-physiological data transmitted electronically Videos, pictures, text messages, audio and any digital form of data. The laws that protect the privacy and confidentiality of health and care information also apply to telehealth/telemedicine. Information obtained during telehealth/telemedicine that identifies me will not be given to anyone without my consent except for the purposes of treatment, education, billing and healthcare operations.

By agreeing to use the telehealth/telemedicine services, I am consenting to Hersmartchoice sharing of my protected health information with certain third parties. I understand, agree, and expressly consent to Hersmartchoice obtaining, using, storing, and disseminating to necessary third parties, information about me, including my image, as necessary to provide the telehealth/telemedicine services.As with any Internet-based communication, I understand that there is 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.Individuals other than my clinical care team or consulting providers may also be present and have access to my information for the telehealth/telemedicine session. This is so they can operate or repair the video or audio equipment used. These persons will adhere to applicable privacy and security policies.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, audio interference) that prevent effective interaction between consulting clinician(s), participant, patient or care team.I hereby release and hold harmless Hersmartchoice and all members of my care team from any loss of data or information due to technical failures associated with the telehealth/telemedicine service.

I understand and agree that the health information 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 at Hersmartchoice.com 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 have the right to withhold or withdraw consent to the use of telehealth/telemedicine services at any time and revert back to traditional in-person clinic services.

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.All my questions have been answered to my satisfaction.

I hereby consent to the use of telehealth/telemedicine in the provision of care and the above terms and conditions.

By signing/agreeing below, I certify that I am the legal representative of the participant or that I am the patient and am 18 years of age or older, or other wise legally authorized to consent. I have carefully read and understand the above statements. I have had all my questions answered. I understand that this informed consent will become a part of my medical record.I have read, understand and agree to the Office and Payment Policies as stated above.

This consent will remain valid indefinitely unless revoked in writing.

‍CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
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‍PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY
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‍Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

‍Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

‍Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations.

‍Terms and Conditions

Insurance - If you are not covered by any insurance plan or this practice is not a participating provider with your insurance plan, full payment of all office visits and other service charges is expected at the time services are provided.Charges for all services are the responsibility of the patient, whether or not covered by insurance. We will file insurance claims for patients if we have a current copy of the patient's insurance card on file. However, all patient payments, noncovered service charges, and deductibles as required by your insurance are due at the time of service. Each insurance plan has a different set of procedures that are eligible for payment, and may have limits on the number and timing of visits, x- rays, and procedures. We may not know at the time of your visit if your insurance company will pay for all services and you may not be notified that a service is not covered at the time of your visit. If your insurance company does not pay for these services, you accept responsibility for full payment of these charges. Charges for certain procedures must be paid for by you prior to having the service provided.The State of California mandates that insurance companies pay for undisputed claims within 45 days of submission. If your insurance company has not paid in full by this time, you will be responsible for all outstanding charges.

Please follow up with your insurance company to make sure they pay your claims. We will refund any overpaid amount to the patient or insurance company as appropriate. We rely on the insurance information you give us in filing insurance claims for you. If we do not have correct insurance information at the time of service we may not be able to file your claim before the "timely filing" period ends. If the insurance information that you provide us is not accurate, you will be liable for the full amount of all charges and agree to pay these charges in full.

Payment -If payment is needed, we accept cash, credit/debit cards.

Account Credits - If you or one of your family members has a credit on their account, you authorize us to use that credit at any time toward payment of any amounts owed on either account. Credits of $20 or less may be left on account without notification.

Delinquent Accounts - Once we have exhausted our internal efforts to obtain payment for service, we will refer accounts to an outside collection agency. These agencies report delinquent accounts to credit reporting services. You will be charged and agree to pay a $50 fee and for all collection and/or attorneys' fees that we may incur trying to collect on your account.

Medical records fee - I understand that federal and state laws allow for a fee to be charged for copying of patient records and I will be personally responsible for the payment of such fees. One copy of up to 75 pages of patient records will be provided at no cost. Any records over 75 pages and any records after the first copy will be billed at the current rates payable prior to records being released.

Deposits: Health insurance is extremely complicated and does not guarantee payments for the services we provide. When we see an insurance that is not 100% clear about reimbursement, we will require a deposit equal or close to the full cash price payment for the service. Insurances take 60-90 days to reimburse for the services. Please contact us 90 days after signing the deposit to 424-666-5525 to verify if your insurance has reimbursed for your service. Once we verify and will release the deposit back to your account. It will be your responsibility to contact us. If you have left a deposit lower than our full cash price for abortion pill and your insurance do not pay the full amount because you have a high deductible or because you don’t have coverage for abortion services, we will have the right to charge the remaining balance at any time to the credit card on file with or without notice.

Safety - For safety and liability reasons, only the patient may be in the treatment room during treatment. Allowing a child in the room while the parent is being treated puts the child at risk for injury from sharp instruments, chemicals, and/or bacteria aerosols present in the room. Children are welcome to wait in the reception room but we are not responsible for the safety or supervision of children in the reception room.

Prescriptions - Please allow 24 hours for processing the refill of any prescription. Current law does not allow narcotics to be prescribed by phone, a written prescription is required. Narcotics will not be prescribed after hours or on the weekends, and lost or stolen prescriptions will not be replaced.