Consent to Receive Principal Illness Navigation Services and Consent to Receive Health Care Services via Telehealth

BRIEF SUMMARY

Aviator Medical Group PA (“Aviator”) provides principal illness navigation services, a type of care management that helps patients understand their medical condition or diagnosis and guides them through the health care system (“Services”). Aviator provides the Services via telehealth modalities, including two-way audio and video communications and asynchronous messaging.

CONSENT TO RECEIVE PRINCIPAL ILLNESS NAVIGATION SERVICES

Before providing Services to you, Aviator is required to obtain your consent to receive the Services and to inform you of the nature of the services, the potential risks and benefits of the Services, and your potential financial responsibility related to the services.

Description of Services

Principal illness navigation services assist patients with serious conditions in navigating their health care treatment. The Services are intended for patients with serious conditions that are expected to last at least three months (like cancer, HIV, or substance use disorder) and that put the patient at high risk for one or more of the following: hospitalization, nursing home placement, a sudden worsening of preexisting symptoms, physical or mental decline, or death. 

To receive the Services, you must have an initial visit with a doctor or other health care provider. After your initial visit, you may receive Services monthly for as long as you need them, through the rest of the year. After one year, you must have another initial visit to determine if you continue to need the Services.

The Services will be provided by your health care provider or trained patient navigator and may include: conducting a person-centered assessment to understand your life story, strengths, needs, goals, preferences, and desired outcomes, including understanding cultural and linguistic factors and unmet social determinants of health needs; facilitating patient-driven goal setting and establishing an action plan; providing support tailored to your treatment plan; identifying and referring you or your caregiver or family member to appropriate supportive services; coordinating receipt of needed services from other health care providers, community-based service providers, or caregivers; communications with your health care providers, service providers, facilities, and caregivers; coordination of care transitions and follow-up visits; providing specific health education to meet your needs and goals; building your self-advocacy skills; helping you access and secure appointments with health care providers; sharing resources regarding clinical trials and research; promoting and supporting your participation in care; and providing social and emotional support to help you meet your diagnosis and treatment goals.

Potential Risks and Benefits and Alternatives

The potential benefits of the Services include better health outcomes, stronger connections to supportive services that assist you in overcoming obstacles to care, and navigation of the complexities of the health care system.

Potential risks include receiving less than optimal Services because of Aviator’s lack of information provided by you or your health care providers, inability to connect you to appropriate services or providers, and risks associated with receiving the Services via telehealth (described further in Consent to Receive Services via Telehealth, below). 

Alternatively, in-person navigation services may be better suited to your needs than Aviator’s remote Services.

Cost-Sharing

Cost-sharing may apply to these Services. For example, if you have traditional Medicare coverage, after you meet your Part B deductible, you pay 20% of the Medicare-approved amount for the Services.

Expected Outcomes

While Aviator cannot guarantee any particular outcomes, you can expect the Services to assist you, as applicable, in receiving prior authorization for health care services, enrolling in financial assistance programs, obtaining and sharing medical records among your health care providers, identifying health care and community-based resources to overcome social barriers to your wellbeing, education, scheduling assistance for services that are part of your treatment plan, and emotional support.

CONSENT TO RECEIVE SERVICES VIA TELEHEALTH

Telehealth involves the use of audio, video, or other electronic communications to interact with you, consult with your health care provider, and review your health information for purposes of diagnosis, follow-up, and/or education. Receiving services via telehealth differs from receiving in-person care. Some of the risks and benefits associated with receiving the Services via telehealth, and alternatives to telehealth, are described below.

Aviator’s platform should not be utilized in a medical emergency. If you are experiencing an emergency, dial 911 or visit the nearest emergency room.

Nature of Telehealth Services, Risks, Benefits, and Alternatives

During your telehealth visits, details of your medical history, personal health information, and life story will be discussed with Aviator personnel using interactive video, audio, and messaging technologies. The benefits of providing the Services via telehealth include your ability to receive the Services from anywhere, without having to travel to an in-person appointment or leave your local community.

The Services do not allow for an in-person physical exemption. The absence of an in-person visit may affect Aviator’s ability to provide the Services. The Services are not intended to replace a full medical evaluation or an in-person visit with a health care provider.

The information transmitted via telehealth may not be sufficient to allow for appropriate health care services. The health information you provide through the Aviator platform and medical records shared with your providers may be the only source of information used to provide the Services. Aviator may not have access to any other medical records or information regarding your condition. Information you provide or share must be true, accurate, and complete. If you provide false, misleading, or incomplete information to Aviator, it may have a negative effect on our ability to provide the Services.

Telehealth presents the risk of potential technical difficulties or delays in connecting with your provider, information lost due to technical failures, or the failure of security protocols causing a breach of patient information. For information about Aviator’s privacy and security practices, please read our Notice of Privacy Practices.

A variety of alternative methods of medical care and patient navigation may be available to you, including in-person services.

Discontinuing Services

You have the right to refuse or discontinue the telehealth Services at any time.

Rights Related to Medical Records

All applicable laws regarding patient access to medical records and copies of medical records apply to records related to telehealth services.

Complaints

If you have any complaints regarding the Services, contact us at hello@aviatorcare.com.

By clicking “I Agree” or “Accept,” in connection with this Consent, you hereby consent, acknowledge, and agree to the following:

1.     You consent to receive electronic communications from Aviator.

2.     You are at least eighteen years old.

3.     You have read and understood the information above regarding the nature of principal illness navigation services, and you agree to receive the Services.

4.     You understand and acknowledge that cost-sharing may apply to the Services, and you may have some financial responsibility related to the Services.

5.     You have read and understood the information above regarding the nature of telehealth services, including the benefits, risks, and limitations of using telehealth, and you agree to receive the Services via telehealth.

6.     You have had an opportunity to ask questions about this Consent, and all your questions have been answered by an Aviator provider.

7.     You are responsible for communicating with Aviator from a private location to maintain your privacy and for security of the electronic device you use for such communications.

8.     Aviator may determine that our Services are not appropriate for some or all your needs and may elect not to provide Services.

9.     You may discontinue the Services at any time.

10.  This informed Consent will become a part of your medical record.