HIPAA Notice | Aviator

Aviator

Informed Consent and Release Agreement

CONSENT TO TREAT

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.

RELEASE OF INFORMATION

I hereby authorize Aviator to use and disclose my (or the patient’s) protected health information (PHI) and medical record information as reasonably necessary to communicate with and obtain information from health care providers and related entities, including but not limited to physicians’ offices, hospitals, clinics, laboratories, imaging centers, pharmacies, and other health care professionals, as well as health plans/insurers, billing entities, and other organizations involved in my (or the patient’s) care. This authorization is for purposes including care coordination, treatment planning, obtaining and sharing medical records, scheduling and follow-up, benefits and eligibility verification, and billing and payment activities, consistent with applicable federal and state privacy laws, including HIPAA. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient as permitted by law, and may affect coverage or benefits determinations.

[Cloud Health Medical] RELEASE OF INFORMATION

Informed Consent to Telehealth and Remote Physiological Monitoring Services

I hereby give my informed consent for medical treatment and procedures to be administered by the healthcare professionals at Cloud Health Medical Group, P.A., Cloud Health Medical Group of California, P.C., Cloud Health Medical Group of New Jersey, P.A., and Cloud Health Medical Group of Kansas, P.C. (collectively “Cloud Health Medical”). Cloud Health Medical provide remote monitoring services to patients (“RPM Services”) using remote monitoring technologies (“RPM Technology”). By agreeing to this informed consent (“Consent”), you have elected to receive RPM Services via telehealth from Cloud Health Medical. If you have questions about use of the RPM Technology itself and whether it is appropriate for your medical condition, the risks associated with using the RPM Technology, or the provider’s credentials and professional background, please ask your Cloud Health Medical provider. All capitalized terms used in this Consent but not defined herein will have the meanings provided in the Consent for Healthcare Services or Notice of Privacy Practices. Only use the Services if you have read this information and subsequently made an informed decision that the Services are right for you. If you have any questions, please email us at legal@usebridge.com.

I understand and acknowledge the following:

1. Nature of Consent:
I understand that by signing this form, I am authorizing Cloud Health Medical and its healthcare providers to provide medical treatment, conduct diagnostic tests, and perform necessary procedures to diagnose and treat my medical condition.

2. Nature of Treatment:
I acknowledge that Cloud Health Medical may employ a variety of medical treatments, including but not limited to examinations, diagnostic tests, medical procedures, surgeries, administration of medication, and the use of medical devices. I understand that alternative treatments, risks, and potential complications will be discussed with me before any procedures are performed.

3. Use of RPM Technology

I understand and agree that:

THE RPM TECHNOLOGY IS NOT AN EMERGENCY RESPONSE UNIT. YOU MUST CALL 911 FOR IMMEDIATE MEDICAL EMERGENCIES

a. Cloud Health Medical provider will decide, in his or her sole discretion, whether it is appropriate to treat your condition using the RPM Technology
b. I, or my Cloud Health Medical provider, may require an in-person examination prior to me receiving RPM services
c. The response time for electronic communications submitted through the RPM Technology varies and I accept any risk associated with the response time, including a delay in obtaining medical care
d. The RPM Technology provided to me is the property of Cloud Health Medical. I will not tamper with the RPM Technology and I understand that I am responsible for any costs and expenses related to the misuse of the RPM Technology

No warranty or guarantee has been made to me concerning any particular result related to my condition or diagnosis.

4. Chronic Care Management (CCM) Services and Billing

I hereby consent to receive Chronic Care Management (“CCM”) services from Cloud Health Medical Group as defined by the Centers for Medicare & Medicaid Services (CMS) under CPT codes 99490, 99439, 99487, 99489, and 99491, and as recognized by my health insurance plan.

I understand that CCM services involve the ongoing management of my chronic medical conditions under the direction of my healthcare provider and may include:

• At least 20 minutes of clinical staff time directed by a physician or qualified healthcare professional per calendar month
• Non-face-to-face coordination and communication, including telephone calls, secure messaging, and review of medical data
• Maintenance and regular review of a comprehensive electronic care plan
• Coordination with other healthcare professionals and community resources involved in my care

a. Acknowledgments and Authorizations

I acknowledge and understand that:

• CCM services are performed under the direction and general supervision of my treating provider at Cloud Health Medical Group.
• Only one provider may bill for CCM services for me during a given calendar month. By signing this consent, I authorize Cloud Health Medical Group to furnish and bill for these services until I revoke this consent.
• I may revoke this consent at any time by providing written notice to Cloud Health Medical Group. Revocation will be effective at the end of the month in which notice is received.
• Participation in CCM is voluntary, and refusal or withdrawal will not affect my eligibility for other medical care or services.
• CCM services may be subject to cost-sharing, including applicable copayments, coinsurance, or deductibles, as determined by my insurance plan (including Medicare and private/commercial insurers).

b. Billing and Privacy

I authorize Cloud Health Medical Group to bill Medicare and/or my private or commercial insurance for CCM services rendered. I agree to pay any patient-responsible amounts in accordance with my insurance benefits.

I understand that Cloud Health Medical Group and its clinical staff may use and disclose my protected health information (PHI) as necessary to provide, coordinate, and bill for CCM services in compliance with applicable HIPAA privacy and security regulations.

By signing below, I acknowledge that I have read and understand this consent form, that my participation is voluntary, and that I consent to receive and be billed for Chronic Care Management services as described above.

Additional State-Specific Consents and Disclosures.

The following consents apply to patients accessing Cloud Health Medical Group’s services for the purposes of participating in a telehealth consultation as required by the states listed below:

Alaska: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter. I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Arizona: I understand I am entitled to all existing confidentiality protections pursuant to A.R.S. § 12-2292. I also understand all medical reports resulting from the RPM Services are part of my medical record as defined in A.R.S. § 12-2291. I also understand dissemination of any images or information identifiable to me for research or educational purposes shall not occur without my consent, unless authorized by state or federal law.

California: I understand that some or all of my CCM services may be provided using telehealth technologies. I consent to the use of telehealth for CCM services in accordance with California law.

I also authorize Cloud Health Medical Group to share my health information among its affiliated entities and care team members for the purpose of coordinating my care, consistent with the California Confidentiality of Medical Information Act (CMIA).

Colorado: I consent to the use of telehealth for my CCM services. I understand that I will not be charged separately for the use of telehealth technology and that my privacy will be protected under Colorado law.

Connecticut: I understand that my primary care provider may obtain a copy of my records, my RPM services and my telehealth encounter.

Florida: To view my rights under Florida’s Patient Bill of Rights and Responsibilities, I should visit the Florida Agency for Health Care Administration or click here. To view my rights under Florida’s Weight-Loss Consumer Bill of Rights, I should visit here.

I understand that my provider may not be physically located in Florida when telehealth CCM services are provided. I consent to receive these services under Florida’s Telehealth Practice Act.

Georgia: I have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the RPM Services.

Hawaii: I consent to the use of telehealth for CCM services as permitted by Hawaii law. I understand that my privacy will be protected under state and federal law and that I may withdraw consent at any time.

Idaho: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Illinois: I understand that telehealth may be used for parts of my CCM care. Participation is voluntary, and I may choose in-person visits when available. I consent to telehealth consistent with Illinois law.

Indiana: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Iowa: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Kansas: I understand that if I have a primary care provider or other treating physician, the person providing telemedicine services must send a report to such primary care or other treating physician of the treatment and services rendered to me during the telemedicine encounter within three days of me providing consent to the person providing telemedicine and RPM services to send such report.

Kentucky: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

Maine: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; or, the Maine Board of Osteopathic Licensure’s website, here.

New Jersey: I understand I have the right to request a copy of my medical information and I understand my medical information may be forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers.

I understand that some of my CCM services may be delivered using telehealth. I have been informed of my provider’s identity, credentials, and location, and I consent to receive telehealth services consistent with New Jersey law.

New Hampshire: I understand that my primary care provider or treating provider may obtain a copy of my records of my telehealth encounter.

New York: I consent to receive telehealth services for Chronic Care Management.

I understand that all telehealth communications will be secure and that my information will remain confidential under New York law.

Ohio: I understand that my primary care provider may obtain a copy of my records of my telehealth encounter.

Oklahoma: I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here; or, the Oklahoma Board of Osteopathic Examiners’ website, here.

Oregon: I consent to receive telehealth Chronic Care Management services under Oregon law. I understand that these services will follow all confidentiality and coordination-of-care rules applicable in Oregon.

Rhode Island: If I use e-mail or text-based technology to communicate with my Perry Health provider, then I understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication should be utilized. I have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy.

I have been informed that if I want to register a formal complaint about a provider, I should visit the medical board’s website, here.

South Carolina: I understand that my medical records may be distributed only with my consent and in accordance with applicable laws and regulations to other treating health care practitioners.

South Dakota: I have received disclosures regarding the RPM Services RPM Technology and limitations.

Texas: I understand that with my consent my medical records may be sent to my primary care physician within 72 hours after receiving Services.

I consent to the use of telecommunication technology, including telephone or electronic communications, as part of my Chronic Care Management services.

I understand that these services will comply with Texas Medical Board telemedicine standards and that I may decline telehealth at any time.

I have also been informed of the following notice:

NOTICE CONCERNING COMPLAINTS – Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353. For more information, please visit www.tmb.state.tx.us.

AVISO SOBRE LAS QUEJAS – Las quejas sobre médicos, así como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018. Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353. Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us.

Utah: I understand (i) any additional fees charged for RPM Services, if any, and how payment is to be made for those additional fees; (ii) to whom my health information may be disclosed and for what purpose, and have received information on any consent governing release of my patient-identifiable information to a third-party; (iii) my rights with respect to patient health information; (iv) appropriate uses and limitations of the RPM Technology, including emergency health situations. I understand that the RPM Services Cloud Health Medical provides meets industry security and privacy standards and complies with all laws referenced in the Utah regulations.

I was warned of potential risks to privacy notwithstanding the security measures and that information may be lost due to technical failures, and agree to hold Provider harmless for such loss.

I have been provided with the location of Cloud Health Medical’s website and contact information. I am able to (i) access, supplement, and amend my patient-provided personal health information; (ii) obtain upon request an electronic or hard copy of my medical record documenting the RPM Services, including the Consent provided; and (iii) request a transfer to another provider of my medical record documenting the telemedicine services.

Virginia: I acknowledge that I have received details on security measures taken with the use of RPM Technology, as well as potential risks to privacy notwithstanding such measures. I agree to hold harmless Cloud Health Medical for information lost due to technical failures, and I provide my express consent to forward patient-identifiable information to a third party.

I consent to the use of telemedicine for my CCM services, consistent with Virginia law. I understand that telehealth services will be conducted securely and documented in my record.

Vermont: I understand that I have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. I understand that receiving telemedicine services via Found’s Platform does not preclude me from receiving real-time telemedicine or face-to-face services with the distant provider at a future date.

I have been informed that if I want to register a formal complaint about a provider, I should visit the Vermont Board of Medical Practice website, here or the Vermont Board of Osteopathic Examiners, here.

Washington: I consent to receive telemedicine as part of my Chronic Care Management services.

I understand that this consent will be recorded in my medical record, and that telehealth services will meet Washington privacy and security requirements.

Washington D.C.: I consent to receive telehealth services as part of my Chronic Care Management. I understand that my provider may not be located in the District of Columbia at the time of service, and that all telehealth interactions will comply with D.C. telemedicine standards.