Reperio Health and Amazon One Medical Redefine the Front Door to Primary Care | Click here to read the press release
Reperio Health and Amazon One Medical Redefine the Front Door to Primary Care | Click here to read the press release
Reperio Health Medical Group, PLLC
This Virtual Visit Agreement (this "Agreement") explains the terms and conditions under which Reperio Health Medical Group, PLLC, Alexander Marsh, M.D., PC, or Reperio Health Medical Group, LLC (collectively referred to hereafter as, "Practice") provides telehealth services (the "Telehealth Consent") and manages recordings and protected health information (the "Consent to Recording of Encounter and Release of Protected Health Information") in connection with your virtual visit. By proceeding with a virtual visit, you accept and agree to be bound by this Agreement.
Telehealth is the delivery of healthcare services when the healthcare provider and the patient (the "Patient" or "you") are not in the same physical location and communicate through technology. Electronically transmitted information may be used for diagnosis, treatment, follow-up, prescribing, or education and may include medical records, medical images, interactive audio, video and/or data communications, and output data from medical devices, sound and video files.
The Patient is hereby advised that the care provided by practitioners through the Practice is not a replacement for an in-person relationship with a primary care provider. If the Patient does not have a primary care practitioner, they are advised to seek the care of one.
The Patient understands the following with respect to telehealth offered by the Practice:
The Patient has elected to have a telehealth visit instead of an in-office visit at the Practice. The Patient agrees that the Practice will determine whether the Patient's condition is appropriate for telehealth and acknowledges that the Practice may recommend an in-person visit in lieu of, or in addition to, the telehealth visit.
The Patient has had an opportunity to review the Practice's credentials and has elected to receive services from the providers at the Practice, understanding that the specific provider assigned to the appointment will be determined based on practitioner availability at the time of service. The Patient has chosen to utilize the Practice's services to see an available provider instead of seeking care from the patient's primary care provider or another provider of the Patient's choosing.
There are potential risks associated with the use of telehealth, including, but not limited to: the information transmitted may be less comprehensive than that available during an in-person visit and may therefore result in decreased accuracy of diagnosis or medical decision-making; delays in medical evaluation or treatment could occur due to deficiencies or failures of the telehealth equipment; security protocols could fail, causing a breach of privacy.
The Patient understands that telehealth often involves electronic transmission of the Patient's protected health information ("PHI"). The Patient's PHI includes, but is not limited to, the Patient's individually identifiable health information; medical history; diagnoses; communications to and from the Patient's other health care provider(s); etc. The Patient understands that PHI may be lost due to technical failures, cyber intrusion or other issues disrupting the Patient's telehealth visit or causing delays in response from the Practice. The Patient assumes these risks and holds the Practice and its providers harmless from any claims arising out of the use of telehealth to conduct the visit. The Patient understands that PHI obtained during the telehealth visit will not be disclosed to others without the Patient's consent unless permitted by applicable law and in accordance with the Practice's Notice of Privacy Practices.
The Patient has the right to request that we submit information about his or her treatment with the Practice to his or her primary care physician. If the Patient makes such a request and consents to the disclosure of PHI, the Practice will send the Patient's medical record, and/or a report containing an explanation of the Patient's treatment, to the Patient's primary care physician within 72 hours of his or her consultation with the Practice.
The Patient acknowledges and understands that the telehealth visit is not intended to support or carry emergency calls to Practice. In the event of a clinical emergency, dial 911 immediately. You acknowledge and agree that: (i) by utilizing the telehealth service the provider encounter is not a replacement for your existing relationship with your primary physician or other primary healthcare provider; (ii) you will contact your primary physician or other primary healthcare provider immediately should your condition change or any symptoms worsen; and (iii) if you require emergency care, you will contact your local emergency services immediately.
The Patient has the right to withhold or withdraw consent for telehealth at any time without affecting the Patient's right to future care, treatment, benefits, or programs for which he or she is otherwise entitled. The Patient understands that if others are present at Patient's location during the Patient's telehealth visit, the confidentiality of the Patient's telehealth visit may be compromised.
The Patient understands the alternatives to telehealth, such as an in-person encounter, as they have been explained, and in choosing to participate in a telehealth visit understands that some parts of the exam may require in-person physical testing to be performed at the direction of the Practice providers.
THE PATIENT UNDERSTANDS THAT PAYMENT RESPONSIBILITY DEPENDS ON THE ENROLLMENT OPTION SELECTED AT SIGN-UP. (I) IF THE PATIENT ELECTS A CASH-ONLY/OUT-OF-NETWORK SERVICE (INCLUDING DIRECT-TO-CONSUMER SCHEDULING WHERE THE PATIENT PROCEEDS AFTER BEING NOTIFIED THAT THE SERVICE IS OUT-OF-NETWORK), THE PATIENT IS FINANCIALLY RESPONSIBLE FOR ALL OUT-OF-POCKET CHARGES ASSOCIATED WITH THE TELEHEALTH VISIT, AND ANY REQUIRED PAYMENT IS DUE PRIOR TO THE TELEHEALTH VISIT. (II) IF THE TELEHEALTH VISIT IS A COVERED BENEFIT UNDER THE PATIENT'S INSURANCE PLAN AND THE PRACTICE PARTICIPATES IN BILLING FOR THAT VISIT, THE PRACTICE WILL SUBMIT A CLAIM TO THE PATIENT'S INSURER; THE PATIENT REMAINS RESPONSIBLE ONLY FOR ANY APPLICABLE PATIENT-RESPONSIBILITY AMOUNTS (E.G., COPAY, COINSURANCE, DEDUCTIBLE, OR NON-COVERED SERVICES), AS DETERMINED BY THE INSURER. (III) IF THE TELEHEALTH VISIT IS PROVIDED THROUGH AN EMPLOYER-SPONSORED PROGRAM IDENTIFIED AT SIGN-UP, THE PATIENT WILL NOT BE RESPONSIBLE FOR PAYMENT FOR COVERED SERVICES, UNLESS THE PATIENT AFFIRMATIVELY SELECTS AN OPTION THAT MAKES THE PATIENT FINANCIALLY RESPONSIBLE.
The Patient understands and agrees that, at the time of each telehealth consultation, the Patient must be physically located in the U.S. state in which the Patient is receiving services. The Patient acknowledges that the platform utilized by the Practice will verify the Patient's location (including through device-based location services) prior to connecting the Patient with a provider, and the Patient consents to such location verification for purposes of confirming the Patient's state and matching the Patient with an appropriately licensed provider. If the Platform is unable to verify the Patient's location, or if the Patient is not physically located in an eligible state, the consultation may not proceed and the Patient may be required to confirm the Patient's current state before continuing. The Patient understands that any provider furnishing telehealth services will be duly licensed to practice in the state corresponding to the Patient's location, and that, prior to initiating any telehealth encounter, the provider may request confirmation of the Patient's identity and physical location.
The Patient understands that the Practice's healthcare professionals may exercise their professional judgment to prescribe medication or other treatment to the Patient specifically to treat the Patient's diagnosed condition, but there is no guarantee that the Patient will be prescribed a medication or other treatment. If a medication or other treatment is ordered, the Patient, at all times, has the ability to request that his or her medication or treatment be fulfilled at the ancillary provider (e.g., pharmacy) of the Patient's choice.
The Patient understands that the Practice may use AI tools, such as generative AI assistants, chat features, and transcription or summarization services, to assist with clinical documentation, drafting visit notes, organizing information, AI internal training, and improving workflow efficiency. These tools do not replace clinical judgment or provide independent medical decisions; the provider remains solely responsible for your diagnosis and treatment. At the outset of each telehealth visit, the provider will provide verbal notice that AI tools may be used in connection with the visit. If audio or video from your visit is processed by AI for transcription or documentation purposes, it will be used and safeguarded in accordance with Section 8, our privacy practices, and applicable law.
By using our telehealth services and consenting to being recorded, you also acknowledge and agree to opt-in so that we may access, use, and share your health information through one or more Health Information Exchanges ("HIEs") with participating healthcare providers and organizations nationwide for treatment, payment, and healthcare operations, as permitted by law. Depending on your state of residence and applicable law, you may request information about HIE participation in your state and how to exercise your opt-in/opt-out choice by contacting us.
You authorize the Practice to use and/or disclose your PHI, including your name, contact information, current and past diagnoses, associated treatment history and recommendations, prescription medication history, and insurance plan information, to Reperio Health, Inc. ("Company").
You consent to the Practice recording your virtual meeting with the Practice's licensed professional (the "Provider") (such meeting being referred to as the "Encounter"), and you grant the Practice and the Company, as its business associate, the non-transferable, non-sublicensable, non-exclusive right and license to photograph or otherwise record you, and to edit, transcribe, use, and reproduce your image, performance, voice, and/or physical likeness, as well as your personal information, including, but not limited to your name and biographical information (individually and collectively, your "Likeness"), in whole or in part, and on a perpetual and worldwide basis, but only in connection with:
1) your health care treatment, as recommended by the Provider during and after the Encounter;
2) the use of de-identified Encounter data for the continued development of AI-powered learning pathways that assist the Practice and its Providers to furnish efficient Encounters; and
3) the use of de-identified data for purposes of enhancing the Company's platform.
De-identification refers to the process of redacting certain PHI to render the data not individually identifiable.
In accordance with applicable state and federal law, you provide your consent to the recording of your Encounters, and you acknowledge that the information disclosed pursuant to this Release may be redisclosed and therefore, no longer protected under HIPAA.
By signing this consent and participating in the Encounter, you acknowledge and confirm your physical location at the time the Encounter begins and provide your prior, informed, and express consent to recording of the Encounter. You acknowledge and understand that your consent is intended to satisfy the requirements of all applicable federal and state wiretapping, eavesdropping, and recording laws, including those in "all-party" or "two-party" consent jurisdictions (e.g., California, Florida, Pennsylvania, Illinois, among others), which require the consent of every participant to a recorded communication. If you are located in an "all-party" or "two-party" consent state, you expressly consent to the recording of the Encounter under the laws of that state.
You understand that this authorization is voluntary. If you do not sign this form, the treatment, payment, enrollment, or eligibility for benefits provided by the Practice will not be affected, except to the extent that your Likeness and recording may be used to: (i) inform a Provider's treatment decisions; and (ii) utilized to facilitate AI-powered support to assist the Provider in the provision of the applicable health care services.
The use of your PHI, as described herein, other than for treatment, payment or healthcare operations, requires your advance written permission.
You may revoke this authorization at any time by submitting written notice to info@reperiomedical.com. You understand that any use or disclosure of your Likeness, any Encounter recording, or PHI obtained from any Encounter recording that occurred prior to the Practice's receipt of your revocation will not be impacted. You understand that your ability to revoke this authorization may be limited in circumstances in which the Practice has taken action in reliance on your authorization.
This authorization will expire upon your express revocation or 10 years from the date of this authorization, whichever is earlier.
You understand that you may request the Practice to provide a copy of this signed form.
You can contact the Practice at info@reperiomedical.com for a copy of this Virtual Visit Agreement or to withdraw your consent as applicable.
The Patient has been advised of all the potential risks, consequences and benefits of telehealth, including risks related to the security of electronic communications. The Patient has been afforded the opportunity to ask questions about the information presented within this Virtual Visit Agreement. All the Patient's questions have been answered, and he or she understands the information contained herein.
By proceeding with a virtual visit, you acknowledge that you have read and understand the terms of this Telehealth Consent, and Consent to Recording of Encounter and Release of Protected Health Information and you voluntarily authorize the use and disclosure of your PHI, which may be obtained through the recording of the Encounters, for the specific purposes described herein.
