INTEGRATIVE PATH ELECTRONIC COMMUNICATIONS AGREEMENT
Integrative Path PC, a North Carolina professional corporation (“we ”, “us ”, or “Practice ”), and the undersigned patient (“Patient ”) enter into this Electronic Communications Agreement (“EC Agreement ”) regarding the use of e-communications/transmissions, such as email, mobile or cellular telephone, Zoom, Spruce Health, Skype, FaceTime, internet portal-enabled communications, or any other version of electronic communication (collectively “E-Communication ”) with respect to Patient protected health information (“PHI ”). (Practice and Patient are each individually called “Party ” or collectively as “Parties ”).
PATIENT AUTHORIZATION DESPITE RISKS OF PRIVACY BREACH
While Practice and Patient commonly rely on electronic communication platforms and services to achieve communication immediacy, there are risks that Patient acknowledges that are outside the control of the Practice. Patient authorizes all forms of E-Communications that the Parties exchange between each other unless Patient instructs us otherwise in writing. Patient acknowledge that the use of E-Communication is inherently risky and prone to unintentional release of data. E-Communications may incorporate or communicate references to Patient’s PHI with sensitive health and personal identification information included. Patient acknowledges that E-Communications lack any absolute guaranty of privacy and are subject to: system privacy failure, cookies and other tracking efforts, phishing attacks, hacking attacks, data breaches, unintended misdirections, misidentifications of senders/recipients, technology failures, and user errors.
Patient agrees to undertake efforts to protect Patient’s privacy, which includes refraining from including sensitive information in E-Communications that Patient does not want to be at risk of any data security breach. Practice will undertake reasonable efforts to protect Patient’s privacy to the extent required by applicable laws. Patient authorizes us to respond electronically to all E-Communications that appear to be provided by Patient, whether or not such communications arrive from the electronic contact information that Patient provides us.
PATIENT MUST PROVIDE ACCURATE AND UPDATED CONTACT INFORMATION
Patient agrees to provide us with Patient’s accurate electronic contact information (mobile telephone number for phone calls and text messaging, email address, Skype or FaceTime contact information, and any other applicable E-Communication contact information). Patient will immediately inform us of any changes or corrections to Patient’s electronic contact information as an effort to avoid misdirected E-Communications.
PATIENT MUST NOT RELY ON ELECTRONIC COMMUNICATION IN EMERGENCIES: USE 911 AND GET TO THE EMERGENCY ROOM
Practice does not guarantee that we will read Patient’s E-Communications immediately or within any specific amount of time. Patient agrees not to utilize E-Communications to contact us about an emergency or time-sensitive situation, as there is too much risk that the communication response may be delayed, ineffective, untimely, or inadequate. Patient MUST call 911 in an emergency, immediately seek emergency medical attention, or both.
PRACTICE WILL COMPLY WITH HIPAA
The Practice values and appreciates Patient’s privacy and will take commercially reasonable steps to protect Patient’s privacy in compliance with the Health Insurance Portability and Accountability Act of 1996 and related laws (“HIPAA”).
We will obtain Patient’s express written or electronic consent (to the extent required by applicable law) if we are required or requested to forward Patient’s identifiable PHI to any third-party other than as authorized in our Notice of Privacy Practices or as authorized or mandated by applicable law.
Patient hereby consents to the use of E-Communication of Patient’s information as we consider it helpful to coordinate care and schedule mobile visits with Patient and all those responsible for providing or overseeing Patient’s care. Patient agrees to identify individuals or entities authorized to receive Patient’s PHI from us in connection with authorized consulting, education, and all other aspects of Patient’s care, and we may share Patient’s PHI with such parties without additional written or electronic consent from Patient.
Patient has the right to ask us for a copy of Patient’s PHI, including an explanation or summary. These services that we perform will not be the subject of additional charges to Patient: maintaining PHI storage systems, recouping capital or expenses for PHI data access, PHI storage, and infrastructure, or retrieval of PHI electronic information.
We may charge Patient fees for actual costs that we incur to provide such electronic PHI, but only to the extent authorized by applicable laws. Such fees may include to the extent lawful: skilled technical staff time spent to create and copy PHI; compiling, extracting, scanning, and burning PHI to media and distributing the media with media costs charged to Patient; and time spent by our administrative staff preparing more explanations or summaries of PHI. If Patient requests PHI on a paper copy, or portable media (such as compact disc/CD, or universal serial bus/USB flash drive), we may charge Patient for our actual supply costs for such equipment, and Patient agrees to pay us any such costs.
PATIENT ACCEPTS RESPONSIBILITY FOR ELECTRONIC COMMUNICATION RISKS
Patient will hold Practice (and our owners, officers, directors, agents, and employees) harmless from and against any and all demands, claims, and damages to persons or property, losses, and liabilities, including reasonable attorney fees, arising out of or caused by E-Communication (whether encrypted or not) losses or disclosures caused by any of the risks outlined above, or caused by some person or entity other than Practice, or not directly caused by us. Patient acknowledges and understands that, at our discretion, E-Communication may or may not become part of Patient’s permanent medical record. These terms do not relieve Practice from Practice’s obligations to comply with all applicable E-Communication laws.
Patient acknowledges that Patient’s failure to comply with the terms of this EC Agreement may lead to our terminating the use of E-Communication methods with Patient and may cause the termination of Patient’s agreement for our services.
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
We are required to provide Patient a copy of our Notice of Privacy Practices, which states how we may or disclose Patient’s health information. Patient hereby acknowledge receipt of the Notice of Privacy Practices.
CONSENT TO DISCLOSURE OF BILLING INFORMATION
By signing this EC Agreement, Patient consents to disclosing all information relevant to billing, insurance, and reimbursement regarding any and all substance abuse disorders that Patient might have, for obtaining reimbursement from private or public insurers.
ADDITIONAL TERMS
This EC Agreement will remain in effect until either Party provides written notice to the other Party revoking this EC Agreement or otherwise revoking consent to E-Communications between the Parties. Such revocation will occur thirty (30) calendar days after written notice of such revocation.
Revocation of this EC Agreement will preclude us from providing treatment information in an electronic format other than as authorized or mandated by applicable law or by Patient. Either Party may use a copy of this signed original EC Agreement for all present and future purposes.
Parties agree to take such action as is reasonably necessary to amend this EC Agreement from time to time as it is necessary for the Parties to comply with the requirements of the Privacy Rule, the Security Rule, and other provisions of HIPAA, or other applicable law. Parties also agree that no one can change, modify, or discharge this EC Agreement unless both Parties write and sign a separate agreement to change the EC Agreement.
If any term of this EC Agreement is found invalid or in violation of any applicable law or public policy, the remaining terms of this EC Agreement shall govern, and this EC Agreement shall be deemed amended to conform to any applicable law.
Each participating patient (and authorized representative when applicable) must sign this EC Agreement. Patient’s signature represents that Patient understands and agrees to the terms and conditions described within this EC Agreement.
INTEGRATIVE PATH PRIVATE PRACTICE PATIENT AGREEMENT
This Private Practice-Patient Agreement (“Agreement ”) specifies the terms and conditions under which, you, the undersigned patient (“Patient ”) may voluntarily elect to participate in the healthcare services offered by INTEGRATIVE PATH PC, a North Carolinian professional corporation licensed to practice medicine (“Practice ”) as described in Schedule A and summarized as follows:
Practice’s comprehensive integrative/Functional Medicine diagnostic routine exam services, provided on a regardless of medical condition or necessity basis, with follow-up routine diagnostic exams as further specified in Schedule A (collectively “Integrative Exams ”); and
An online health data storage and communication facilitation platform plan designed to provide efficient and reliable electronic communication and health data storage support for Integrative Exams and to help Patient to achieve Integrative Exams-based health goals (“Health Data Services ”). Integrative Exams and the Health Data Services described in Schedule A are collectively the “Integrative Exam Services ” and Patient and Practice are referred to individually as “Party” or collectively as the “Parties. ”
INTEGRATIVE EXAM SERVICES
Practice makes Integrative Exam Services available to Patient in exchange for Patient’s payment of the program subscription fees outlined in Schedule A (“Services Fees”). Services Fees may increase from time to time with Patient’s voluntary consent in advance but will apply to renewal terms. If Services Fees increase, Practice will notify Patient in writing with the option to consent to the increase.
Practice reserves the right to update the Integrative Exam Services in Schedule A from time to time, and if it does, Practice will notify Patient of any changes within thirty (30) days after a change is made and shall secure Patient’s voluntary consent to any such modification of Integrative Exam Services or Services Fees. Integrative Exam Services exceed or are beyond those covered by Patient’s Medicare, Medicaid, or private insurance plan (collectively “Plan”). Because Integrative Exam Services include integrative/functional medicine alternatives, Patient provides informed consent to such services as documented in the attached Schedule B.
PAYMENT OPTIONS
Patient may pay the Services Fees with a credit card either monthly, bi-annually, or annually. Services are designed to allow Patient to pay Services Fees with health saving account (“HSA”) funds or with flexible spending account (“FSA”) or health reimbursement account (“HRA”) funds, but Patient must confirm eligibility with Patient’s tax expert or FSA/HRA plan coordinator as Practice cannot guaranty eligibility due to variable factors applicable to each Patient. Services Fees cover the availability of the Integrative Exam Services selected by and subscribed to by Patient for a period of one (1) year.
RENEWALS AND TERMINATION
This Agreement will automatically renew one (1) year from the date of this Agreement unless the Practice receives written notice from Patient to terminate this Agreement thirty (30) days before Patient’s renewal date or Practice terminates the Agreement. Failure to pay the renewal Services Fees before the expiration of the prior period may result in termination of this Agreement. The Practice is permitted to terminate this Agreement with thirty (30) days’ prior written notice to Patient, in which case Patient will receive a prorated refund of the Services Fees but the delivery of any Integrative Exams renders Services Fees substantially earned by Practice. Cancellation requirements and fees are as published as Practice policies, and subject to periodic modifications by Practice.
HEALTH CARE SERVICES EXCLUDED FROM SERVICES FEES
Services Fees cover only the availability of Integrative Exam Services subscribed to by Patient as described in this Agreement and Schedule A. If the Practice provides services other than the Integrative Exam Services described in this Agreement and listed in Schedule A, the Parties may agree upon any additional charges, if any, to the extent the Patient’s Plan does not cover those services. Patient acknowledges that either Patient or Patient’s Plan will be responsible for such additional charges for services outside of Services. Any charges to Patient for any services outside of Plan coverage and Integrative Exam Services will be at Practice’s usual, reasonable and customary rates with Patient’s advance consent. Plan co-payments, deductibles, and the costs for all services other than Integrative Exam Services are the sole responsibility of the Patient.
EMAIL COMMUNICATIONS
If Patient wishes to communicate through email with the Practice, Patient needs to be aware that email may not always constitute a secure medium for sending or receiving sensitive personal health information. Practice will take reasonable steps to keep Patient’s communications confidential and secure and comply with applicable health data privacy obligations under applicable laws. Please refer to Practice’s separate Electronic Communications Agreement for further applicable details in this regard, which is integrated herein by this reference.
APPOINTMENTS AND SCHEDULING
Appointments with the Practice are scheduled through the Practice office to ensure ample time is given to each Patient. If Patient has an urgent concern, Patient shall call the Practice office and Patient will be given an appointment that will accommodate the urgency. Walk-ins are not conducive to the thoughtfully planned schedule, so we advise Patient to schedule appointments in advance.
MEDICARE/PRIVATE INSURANCE
If Patient is or becomes Medicare eligible, Patient acknowledges that Practice is a participating Medicare provider and claims will be submitted to Medicare for all Medicare-covered services provided to Patient by Practice. Patient shall not and agrees not to submit Services Fees to Medicare for reimbursement.
The following Medicare reimbursed services (and any version of the following covered by any Plan) are excluded from Integrative Exam Services, and may be provided and submitted to the appropriate Plan for reimbursement (co-payments and deductibles will apply per Plan requirements): Chronic Care Remote Physiologic Monitoring/RPM; Virtual Check-Ins; Chronic Care Management/CCM; Principal Care Management/PCM; Transitional Care Management/TCM; Behavioral Heath Integration/BHI and Psychiatric Collaborative Care Management Services; Virtual Evaluation & Management; Virtual Annual Wellness Visit; Cognitive Assessment and Care Plan Services.
VACATIONS AND ILLNESS FOR PRACTICE PHYSICIANS
Patient acknowledges that there may be times that Patient cannot contact a Practice healthcare professional due to vacations or illness, or due to technical defects with either Patient’s or Practice’s electronic communication equipment. Patient acknowledges that, should a Practice healthcare professional become unavailable, the Practice shall make every effort to give advance notice to Patient so that scheduled Integrative Exam Services can be scheduled on another date. In all cases of emergency, Patient must call 9-1-1 and/or seek emergency/ER medical attention.
COMPLIANCE WITH LAW
In establishing the Integrative Exam Services programs, Practice intends to do so in compliance with all applicable laws. This Agreement shall be governed by and construed in accordance with the laws of the state in which Practice is licensed and practicing, without application of choice-of-law principles.
PRACTICE IS NOT AN INSURER
Practice is not an insurance company and is not promising or delivering unlimited care for Services Fees. The Practice presumes that Patient is either eligible for Medicare, or otherwise has a private Plan that provides health care coverage for essential healthcare services not covered by the Services Fees.
AGREEMENT ASSSSIGNMENT AND MODIFICATIONS
Patient may not assign this Agreement. This Agreement replaces and supersedes all prior agreements of any kind, oral or in writing, between Patient and Practice. This Agreement may not be modified absent a writing signed by Patient and an authorized representative of Practice.
PATIENT ACKNOWLEDGES THAT HE/SHE HAS CAREFULLY READ THIS AGREEMENT, WAS AFFORDED SUFFICIENT OPPORTUNITY TO CONSULT WITH LEGAL COUNSEL OF HIS/HER CHOICE AND TO ASK QUESTIONS AND RECEIVE SATISFACTORY ANSWERS REGARDING THIS AGREEMENT, UNDERSTANDS HIS/HER RESPECTIVE RIGHTS AND OBLIGATIONS UNDER THIS AGREEMENT, AND SIGNS THIS AGREEMENT OF HIS/HER OWN FREE WILL AND VOLITION.
By signing below, I am agreeing to enrollment in the Practice and the terms of this Agreement as detailed above and in Schedule A and B.
INTEGRATIVE PATH NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY
Dear Patient:
INTEGRATIVE PATH PC, a North Carolinian professionals corporation (“we”, “us”, “our”, or “Practice”), understands that Patient (“you”, “your”) privacy is important. This Notice of Privacy Practices (“Notice”) applies to Practice and each of our Business Associates, as applicable.
PROTECTED HEALTH INFORMATION
Protected health information (“PHI ”) relates to information about you and your health, which could be used to identify you. Each time that you visit us, we create a medical record of your PHI and services that you receive.
OUR OBLIGATION REGARDING YOUR PROTECTED HEALTH INFORMATION
We recognize that information about you and your health is confidential, and we are committed to protecting this information. This Notice applies to all your health records that we create.
We are required by law to preserve the privacy and security of your PHI. While there is no absolute guarantee of privacy, we are committed to protecting your privacy. We have established reasonable and appropriate measures to protect your PHI against unauthorized uses and disclosures.
Federal law mandates that we share this Notice with you, and that we make a good-faith effort to obtain a signed document acknowledging your receipt of this Notice. We are also required to follow the terms of this Notice. If we are involved in a breach of your PHI, we will immediately notify you.
NOTICE EFFECTIVE DATE AND POTENTIAL CHANGES
This Notice became effective on December 1, 2020, and it applies to health records that we create for you. We reserve the right to change this Notice after the effective date. We can change the terms of this Notice, and the changes will apply to all the information we have about you. The new Notice will be available upon request.
HOW WE MAY DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The laws of the state where Practice is located, and federal laws, allow disclosures of your PHI in some cases. Some of these disclosures do not require your verbal or written permission. The following information describes how we may share your PHI. We may typically use or share your PHI in these ways:
TREAT YOU
We can use your PHI and share it with other professionals who are treating you.
Example: We use health informtion about you to manage your treatment and services.
RUN OUR ORGANIZATION
We can use and share your PHI to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services. BILL FOR YOUR SERVICES
We can use and share your PHI to bill and obtain payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services. HELP WITH PUBLIC HEALTH AND SAFETY ISSUES
We can share your PHI for certain situations such as
Preventing disease; Helping with product recalls; Reporting adverse reactions to medications; Reporting suspected abuse, neglect, or domestic violence; and Preventing or reducing a serious threat to anyone’s health or safety. PERFORM RESEARCH
We can use or share your PHI for health research.
COMPLY WITH THE LAW
We will share your PHI if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
RESPOND TO ORGAN AND TISSUE DONATION REQUESTS
We can share your PHI with organ procurement organizations.
Work with a medical examiner or funeral director.
We can share your PHI with a coroner, medical examiner, or funeral director when an individual dies.
ADDRESS OTHER GOVERNMENT REQUESTS
We can use or share your PHI:
For workers’ compensation claims; For law enforcement purposes or with a law enforcement official; With health oversight agencies for activities authorized by law; and For special government functions such as military, national security, and presidential protective services. RESPOND TO ORGAN AND TISSUE DONATION REQUESTS
We can share your PHI in response to a court or administrative order, or in response to a subpoena.
HOW ELSE CAN WE USE OR SHARE YOUR PHI?
We are allowed or required to share your PHI in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. We have not listed every use and disclosure in this Notice.www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
USE AND DISCLOSURE OF YOUR PHI WITH YOUR VERBAL AGREEMENT
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
Share information with your family, close friends, or others involved in your care; Share information in a disaster relief situation; and Include your information in a hospital directory. If you cannot tell us your preference, for example, if you are unconscious, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
USE AND DISCLOSURE OF YOUR PHI REQUIRING YOUR WRITTEN PERMISSION
If there are situations that have not been described above, we will obtain your written permission. In these cases, we never share your PHI unless you give us written permission:
Marketing purposes; Sale of your information; andMost sharing of psychotherapy notes. With fundraising, we may contact you for fundraising efforts, but you can tell us not to contact you again.
If you provide us with written permission, you may change your mind at any time. Please let us know in writing if you change your mind.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding your PHI that is created in our practice. This section explains some of your rights and our responsibilities to assist you.
GET AN ELECTRONIC OR PAPER COPY OF YOUR MEDICAL RECORD
You can ask to see or receive an electronic or paper copy of your medical record and other PHI that we have about you. Ask us how to do this. We will provide a copy or a summary of your PHI, usually within 30 days of your request. We may charge a reasonable cost-based fee. ASK US TO CORRECT YOUR MEDICAL RECORD
You can ask us to correct PHI about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we will tell you why in writing within 60 days. REQUEST CONFIDENTIAL COMMUNICATIONS
You can ask us to contact you in a specific way (for example, home or office phone), or to send mail to a different address. We will say “yes” to all reasonable requests. ASK US TO LIMIT WHAT WE USE OR SHARE
You can ask us not to use or share certain PHI in connection with our services. We are not required to agree to your request, and we may say “no” if it would affect your care. Because you are privately paying for some medical or health services, you may ask us to refrain from sharing information related to those private pay services with your health insurance plan. We will respect that request unless we are legally obligated otherwise under applicable laws. GET A LIST OF WHO WE HAVE SHARED INFORMATION
You can ask for a list (accounting) of the times we have shared your PHI for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting per year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. GET A COPY OF THIS NOTICE
You can ask for a paper copy of this Notice at any time, even if you have agreed to receive this Notice electronically. We will provide you with a paper copy promptly. CHOOSE SOMEONE TO ACT FOR YOU
If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. ASK QUESTIONS TO FILE A COMPLAINT IF YOU BELIEVE YOUR RIGHTS ARE VIOLATED
If you have questions about this Notice or you believe that your rights are being violated, please contact us immediately: PRACTICE CONTACT INFORMATION:
Integrative Path PC (attention: Dr. Ruth Lininger)
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints.
Please provide as much information as possible so that the Department of Health and Human Services can thoroughly investigate your concern or complaint. We will not retaliate against you for filing a complaint with us, or the Department of Health and Human Services.INTEGRATIVE PATH PC
INTEGRATIVE PATH ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Notice to undersigned patient (“Patient ”):
INTEGRATIVE PATH PC, a North Carolina professional corporation, must provide Patient with a copy of Practice’s Notice of Privacy Practices (“Notice ”), which states how Practice may use Patient’s health information, disclose Patient’s health information, or both.
Please sign this form to acknowledge receipt of the Notice.
Patient may refuse to sign this acknowledgment if Patient wishes.
I acknowledge that I have received a copy of Practice’s Notice of Privacy Practices.
