• Date Format: MM slash DD slash YYYY
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  • PATIENT CONSENT FORM CONSENT FOR TELEMEDICINE CONSULTATION

    I hereby authorize SM Concierge Medicine, its subsidiaries/affiliated/contracted entities (“Company”), and its related and/or contracted physicians, other health care professionals, employees, and contractors (the “Professionals”), to use telehealth* in the course of the telemedicine consultation utilizing our proprietary system, methods, and protocols (the “Consultation Services”). I HEREBY REQUEST AND CONSENT TO THE CONSULTATION SERVICES TO BE PROVIDED BY COMPANY AND THE COMPANY PARTIES. I understand that telehealth involves the communication of my medical information, both orally, in writing, and visually, to physicians and other healthcare practitioners at other locations. I understand that the physician-patient relationship, if any, between myself, Company, and the Professionals, is explicitly limited in nature to the Consultation Services, and nothing else. I further understand that, even if I have health insurance of any form, that the Consultation Services are private-pay and are likely not coverable by such insurance. I agree to NOT bill any insurer that may cover me for the Consultation Services, and acknowledge that Company and the Professionals will not be billing any 3rd party for the Consultation Services.
    Consultation Services Specifically

    1. PREGNANCY AND BREASTFEEDING: I UNDERSTAND THAT IF I AM PLANNING TO BECOME PREGNANT, AM CURRENTLY PREGNANT, OR AM BREASTFEEDING, THAT I WILL: (A) ADVISE COMPANY AND THE COMPANY PARTIES OF THIS; AND (B) ASK MY OB/GYN OR PEDIATRICIAN IF THE TREATMENTS RECOMMENDED BY THE COMPANY PARTIES ARE ACCEPTABLE DURING THIS PERIOD OF TIME.

    2. OUTCOMES NOT GUARANTEED: Neither Company nor the Professionals guaranty outcomes based on utilizing the Consultation Services or products or medicines associated with the Consultation Services. I acknowledge that my condition for which I am seeking treatment may get worse, and I am subject to the risks further described below, including risks that my condition may worsen. I agree that I will not be entitled to a refund or recompense from Company or the Professionals for any reason, including poor outcomes.

    3. Company Does Not Provide or Pay For Prescribed/Recommended Medicines, or Other Courses of Treatments: I understand that the fees that I pay Company and/or the Professionals DO NOT include the costs of any prescription drugs or medicines, or other courses of treatment, that may be recommended/prescribed by Company or the Professionals. I understand that I am wholly responsible for the payment of any such drugs or medicines or treatments.

    4. I understand that all health care treatments can have potential adverse side effects and I accept responsibility for these potential adverse outcomes.

    5. If adverse effects are noted, I understand that it is my responsibility to stop all treatments recommended by the Professionals, and to report any adverse side-effects to Company, the Professionals, and to go to the nearest Emergency Room if necessary.

    6. I understand that once the Professionals decide on the treatments and medications to be issued, if any, it is my responsibility to read and understand the side-effect profile of the medications and the adverse drug interactions of the medications and other medications I may be taking.

    7. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than the health care professional in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

    8. I understand that I will be responsible to pay the Company according to the fee schedule included in the Private Pay Agreement.


    Telehealth

    1. I understand that while the Professionals will make every attempt to accurately diagnose and treat my healthcare condition for which I am seeking a teleconsultation, there is still some inherent uncertainty and inaccuracy with delivering healthcare over the Internet. I accept that the “physical exam” portion of the online visits, if any, will be done via pictures, twoway audio/video consultation, questionnaire, relying upon my medical records, or otherwise, which is an accepted method for teleconsultations and is agreed to be an appropriate prior examination made in good faith. I accept this, with all potential benefits and consequences, and deem this method of physical examination appropriate and complete.

    2. I understand that I have the option to withhold or withdraw my consent to receive the Consultation Services via telehealth at any time, but that doing so will cause Company and the Professionals to discontinue providing future care or treatment, it being acknowledged that Company and the Professionals will only be treating me via telehealth methodologies. In such case, I understand that I will need to seek treatment elsewhere.

    3. I understand the potential benefits of telehealth, which include having access to medical specialists and additional medical information and education.

    4. I understand the potential risks and consequences of telehealth, which include that because of my specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment, and the telehealth care provider may not be able to accurately diagnose my condition due to limitations inherent in using a non-face-to-face encounter. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a facetoface visit with a physician.

    5. I understand that all laws about the confidentiality of medical information apply to telehealth information.

    6. I understand that all laws about patient access to medical information and copies of medical records apply to telehealth records.

    I have read and understand the written information provided above. I agree that the information provided above adequately explains the Consultation Services to me, along with the risks and benefits of said Consultation Services. I have had the opportunity to ask questions about this information – if I had any questions, all of my questions have been answered in full by Company, the Professionals, and/or their designees. Further, I represent that I have read and fully understood and agreed to: (i) the Company Private Pay Agreement; (ii) the Company Notice of Medical Information Privacy Practices; and (iii) the Company Privacy Policy;


    THIS FORM MUST BE PLACED IN THE MEDICAL RECORD. A COPY MAY BE GIVEN TO THE PATIENT.

    "Telehealth” means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.

    Online prescriptions will only be issued when indicated and approved by a physician, and as permitted by law in your state.


  • Type your full name and date to accept the terms listed above:
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  • SM CONCIERGE MEDICINE PRIVATE PAY AGREEMENT

    Advance Beneficiary Notice


    Note: You need to make a choice about receiving these health care services.
    The purpose of this form is to help you make an informed choice about whether or not you want to proceed to receive the consultation service, knowing that you will have to pay for it yourself. Private insurance plans and Medicare/Medicaid do not pay for online healthcare , telehealth or second opinion services of the type that we offer. The fact that private insurance plans and Medicare/Medicaid do not pay for this unique service, however, does not mean that you should not receive it.


    Note: Your health information will be kept strictly confidential. Any information that we collect about you through a TELECONSULTATION will be kept strictly confidential and treated as any other medical record utilizing the national guidelines set forth in the Health Insurance Portability and Accountability Act (“HIPAA”), and will be subject to our Medical Information Notice of Privacy Practices (available below), and Terms of Use/Privacy Policy (also available below).

    PRIVATE PAY CONTRACT
    This Private Pay Contract (“Agreement”) is made between SM Concierge Medicine PL, its subsidiaries/affiliated/contracted entities, with a conducting business address of 4308 Alton Rd, Suite 920 Miami Beach, FL 33140 (“Company”), and the client/parent/legal guardian identified below (“Client”). This Agreement is made by Company for itself and on behalf of its related entities and/or contracted physicians, other health care professionals, employees, and contractors (the “Professionals”). Company is not necessarily the provider of medical services; medical treatment may be provided to Clients utilizing a separate entity or by Professionals who are medical professionals.
    The Client may receive a copy of this Agreement at Client’s email address by requesting a copy via e-mail at info@smconciergemedicine.com, or writing to 4308 Alton Rd, Suite 920 Miami Beach, FL 33140; Company will provide a copy of this Agreement to you within five (5) days of receiving your request.
    The Client desires unique services and benefits to be provided by Company/the Professionals that are likely not covered or otherwise likely not reimbursable under a private health insurance policy, private health plan, or federal or state government program, including, but not limited to, Medicare/Medicaid/Tri-Care, in which Client might be enrolled (each an “Insurer”).Company/the Professionals desire to provide unique services and benefits to Client for which Company/the Professionals likely cannot, and in any event will not, seek reimbursement for with an Insurer in which Client might be enrolled.
    By electronically signing this Agreement, Client and Company/the Professionals hereby agree, for valuable consideration, to enter into a relationship for the provision of specified services under the following terms and conditions.

    Client Responsibilities
    In addition to any other responsibilities and/or obligations Client has under this Agreement, Client specifically agrees to the following:

    • Client is responsible for providing Company with accurate and complete medical records, patient history, and descriptions of Client’s condition and physical well-being. Client understands that, as with any service, to the extent that information provided is not accurate and complete, Company’s Services will be materially affected.

    • Client will provide and/or facilitate the provision of all related medical records to Company, and will bear all costs associated with the same. In particular, Client is responsible for requesting that copies of Client’s medical records be sent to Company, and filling out any necessary patient authorization forms related to the same if applicable.

    Jurisdiction and Practice of Medicine for Second Medical Opinion Throughout the GPS Telemedicine Portal Client acknowledges, understands, and agrees that by Client’s seeking to use Company’s services for Second Medical Opinions,

    Client is:
    • Virtually travelling to the State where the Professional is located, and for convenience and other purposes availing themselves of Company’s Services in said State in the same manner as if Client had driven to such State;

    • Irrevocably agreeing that the Services and this Agreement are provided, and entered into, in the State where the Professional is located, and not in the state where Client is physically located. Further, Client agrees that they will not bring any action in the state where Client is physically located, it being acknowledged that sole jurisdiction and venue are in the State of Florida, and that Client has no rights vis-à-vis the Company or the Professionals in their state;

    • To the extent that the state where Client is physically located attempts to assert jurisdiction over the Company or the Professionals, whether through its state professional licensing board(s) or otherwise, Client agrees to cooperate with Company/the Professionals, and otherwise use Client’s best efforts, with respect to asserting the matters agreed to in this Section.

    ◦ In connection with the foregoing, Client acknowledges that, due to the limited nature of the Services, the Services do not constitute the practice of medicine, but are merely a report or findings of a review of the Client’s medical information and history with respect to a condition for which the Client is seeking a second opinion. Reports or results provided by Company under this Agreement shall in no way be considered medical advice or be deemed the practice of medicine by Company or the Professionals, and is not intended to replace consultation with a qualified medical professional. Client acknowledges and agrees that the information contained in the report issued by the Company/Professionals are not intended to diagnose health problems or to take the place of professional medical care. The information contained in the report is neither intended to dictate what constitutes reasonable, appropriate or best care for any given health issue, nor is it intended to be used as a substitute for the independent judgment of a physician for any given health issue.


    Our Services
    Company and/or the Professionals agree to perform second opinion consultation services via telehealth related to Client’s current diagnosis and/or treatment plan which has been provided by an unaffiliated health care professional, all utilizing GPS Telemedicine Portal, methods, and protocols (the “Services”). The Services may be amended or modified to the extent necessary to reflect any change in interpretation or terms of coverage and benefits of any private health insurance policy, private health plan or government program, including, but not limited to, Medicare, in which Client is enrolled.
    Fees and Deliverables
    In return for these Services, the undersigned Client agrees to provide payment to Company in the following amounts and payment schedules (“Fees”):

    1 The rate of the physician on your choice in the Request a Second Opinion Page.

    THE FEES DO NOT INCLUDE THE COSTS OF ANY PRESCRIPTION MEDICINES OR OTHER TREATMENTS THAT MAY BE RECOMMENDED/PRESCRIBED BY COMPANY OR THE PROFESSIONALS. I UNDERSTAND THAT I AM WHOLLY RESPONSIBLE FOR THE PAYMENT OF ANY SUCH DRUGS OR MEDICINES OR TREATMENTS.
    The Fees set forth above may be changed by Company upon reasonable prior notice; in such event Client may cancel as set forth below prior to incurring the changed Fees. Company may, but is not required to, offer discounted Fees or types of incentives to Client from time-to-time. Company may also offer discounted Fees or other types of incentives to other customers of Company, without changing Client’s liability for the Fees incurred hereunder, it being explicitly agreed that Company is under no obligation to extend such other discounted fees or incentives to Client.
    Client agrees and acknowledges the following regarding the Fees:

    • No refunds will be issued for any Fees, no warranties of any type are associated with the Services, and by their nature the Services are not returnable;

    • No other cancellation, refund, or return policy applies to the Services. The Client may cancel at any time by e-mailing info@smconciergemedicine.com, or writing to 4308 Alton Road Suite 920, Miami Beach , Florida, 33140. Regardless of cancellation, no refunds will be issued; and

    • Client acknowledges that Client is capable of printing and/or otherwise retaining a copy of this notice and Agreement, including the provisions set forth above regarding how the Client may cancel this Agreement.

    Agreements Regarding the Services
    Client agrees, and understands that the Services are unique and provided with certain benefits and limitations, including as follows:

    1 Client agrees to be fully responsible, for payment of the Services, and understands that no Insurer reimbursement will be provided.

    2 For Services provided herein, Client cannot, and will not, bill to or seek reimbursement from any Insurer in which Client is enrolled. Client agrees not to submit a claim (or request that Company or the Professionals submit a claim) for the services provided pursuant to this Agreement, to any Insurer.

    3 Services are not covered and otherwise not reimbursable by any Insurer.

    Accordingly, Client understands and acknowledges that the Services convey value and benefits that Client does not already receive from any Insurer in which Client is enrolled. To the extent any one or more element of the Services are considered covered and reimbursable benefits, the Fee is consideration for the remaining items/portions of the Services.

    4 Client understands that no Insurer reimbursement limits (including Medicare’s limiting charge) apply to the services in question.

    5 Client understands that Medi-Gap plans do not, and other supplemental insurance plans may not, make payment for the services because payment is not made under the Medicare program.

    6 Client acknowledges that they have the right to have these items and services provided by other physicians for whom Insurers may make payments.

    7 Client understands that Insurer payment will not be made for any items or services furnished by the physician that otherwise would have been covered by an Insurer if there was no private contract and a proper Insurer covered claim.

    8 Client understands that he/she enters into this contract with the knowledge that he or she has the right to obtain Insurer covered services and items from other physicians, and

    that the beneficiary is not compelled to enter into private contracts that apply to other Insurer services furnished by other physicians who have not opted out.

    1. Client is not currently facing an emergency or urgent health care situation.

    2. Physicians associated with Company and/or the Professionals have not been excluded from the Medicare program.

    11 Company may cancel the Services at any time by providing Client notice of Company’s cancellation.

    Client represents that he/she has read and fully understood and freely covenant to accept and agree to the rights and obligations under this Agreement. Further, Client represents that they have read and fully understood and agreed to the Company’s: (i) Client Consent form for Telemedicine Consultation; (ii) Acknowledgment of Limited Physician-Client Relationship; (iii) the Company Notice of Medical Information Privacy Practices; (iv) the Company GPS Telemedicine PortalTM Privacy Policy; and (v) the Company GPS Telemedicine PortalTM Terms of Use.

    Notice of Medical Information Privacy Practices

    By signing, Client acknowledges Client’s receipt of Company’s Notice of Privacy Practices,, which provides information about how Company may use and disclose Client’s protected health information. We encourage Client to read it in full. The Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by acontacting our organization at: (855) 544-3258. If you have any questions about our Notice of Medical Information Privacy Practices, please contact info@smconciergemedicine.com



  • Type your full name and date to accept the terms listed above:
  • Date Format: MM slash DD slash YYYY