InTeleDerm
is
registered to do business as InTeleDerm. By utilizing InTeleDerm you acknowledge the following: (1) your acknowledgement that you have either received or
that you were provided a reasonable opportunity to electronically review the
notice of InTeleDerm’s notice of privacy practices (“Notice of Privacy
Practices) and (2) your consent for InTeleDerm’s and its designees’ use and
disclosure of your protected health information (“PHI”) for treatment,
payment or healthcare operations as defined by the Health Insurance
Privacy and Accountability Act of 1996 (the "HIPAA Privacy Rule") in
connection with the telehealth dermatology services
(referred to as
the
“InTeleDerm® Service” or “InTeleDerm Service”) which are
provided to you by InTeleDerm
(“InTeleDerm”). The InTeleDerm
Service comprises a network of participating dermatologists (“Participants)
which delivers dermatology services on a telehealth basis through the website
located at http://www.InTeleDerm.com (“Website”).
By submitting your information to the InTeleDerm Service, using the Website in order to request
telehealth dermatology services, your PHI will be made available online through
the InTeleDerm Service.
Participants will have access to your PHI by using the InTeleDerm Service to review your request for telehealth
dermatology services. InTeleDerm
will have access to your PHI as the Administration of the InTeleDerm Service. InTeleDerm’s
designated payment processor will have access to your PHI for use in connection
with payment related activities. Other third parties may have access to
your PHI either to fulfill healthcare operations of the Participants or as a
result of a valid authorization which you have granted.
Please read the
following information carefully:
1. I
understand and consent to the use and/or disclosure of my PHI by InTeleDerm and its designees for the
purposes of treatment, payment, and healthcare operations related activities
which are permitted by the HIPAA Privacy Rule.
a. As
a result of your submitting your PHI to the InTeleDerm Service to request delivery of online teledermatology
Participants will have the ability to access your PHI for the provision of
teledermatology medical services using theInTeleDerm Service. Your PHI will be disclosed and used
by the Participant who has elected to fulfill your request for such
services. Your PHI will be accessed, stored, and maintained online by InTeleDerm and its designees.
b. When
you pay for dermatology services which are delivered through the InTeleDerm Service, your PHI will be
used or disclosed by the third party payment processor in connection with the
processing of your payment information. In addition, your PHI may be
disclosed to or used by a Participant in connection with payment related
activities. InTeleDerm and
its designees may use your PHI for other payment or reimbursement activities
for the provision of services.
c. Participants
and business associates (e.g., entities which perform functions such as
e-prescribing, data center hosting, managed security services, and ongoing
software development and support) may use or disclose your PHI in connection
with healthcare operations related activities such as communications about your
treatment, case management, care coordination, direct or alternative
treatments, therapies, health care providers, or settings of care, and
communications pursuant to a valid authorization by you.
2. I
am aware that InTeleDerm
maintains a Notice of Privacy Practices which explains the types of uses and
disclosures that InTeleDerm and
its designees that are permitted or required to make under the HIPAA Privacy
Rule. By signing this Consent, I acknowledge that I have received a copy
of the Notice of Privacy Practices.
3. I
understand and acknowledge that, in its Notice of Privacy Practices, InTeleDerm has reserved the right to
change its Notice of Privacy Practices as permitted or required by the HIPAA
Privacy Rule. I understand that I may obtain a copy of the Notice of
Privacy Practices at any time by sending a written request to the following
address:
InTeleDerm, Attn: Privacy Officer, 21346 Brewers Farm
Lane Carrollton, VA 23314.
I understand and acknowledge
that I have the right to request restrictions on how my PHI is used or
disclosed to carry out treatment, payment or healthcare operations or to
restrict uses and disclosures to those who are involved in my care or payment
of my care.
5. I
understand and acknowledge that InTeleDerm
is generally not required to agree to restrictions requested by me regarding my
PHI. However, InTeleDerm reserves
the right to not provide care if such restrictions are requested by me; in such
a case, I understand that I will not be eligible to use the InTeleDerm Service if InTeleDerm exercises that right.
6. I
understand and acknowledge the risks of electronic communications (e.g., via
the InTeleDerm Service, text
messages, and email) in that they are not secure and I consent to receiving
such communications. If any PHI is communicated, then only the minimum
necessary amount of PHI will be used.
