Informed Consent for Telehealth Services

Care for Hearts Medical Practice

1. Introduction and Services

DO NOT USE THIS SERVICE IF YOU ARE OR MAY BE EXPERIENCING A MEDICAL EMERGENCY. If you may be or are experiencing a medical emergency, call 911 or go to the nearest emergency room.

We are pleased you have chosen Care for Hearts Medical, LLC, a Delaware limited liability company, or its affiliates Care for Hearts Medical, NJ, LLC a New Jersey limited liability company, Care for Hearts Medical CA, PC, a California professional corporation, and Care for Hearts Medical KS, LLC a Kansas professional limited liability company (collectively, “We” or “Care for Hearts Medical Group”) whose licensed physicians, pharmacists, nurses, and other professionals (“Providers”) can provide you with certain telehealth services described below. These services are facilitated through the Care for Hearts Medical Group online platform, connected mobile applications (e.g., your Hello Heart mobile app), or other telehealth technologies (collectively, the “Platform”). 

Care for Hearts Medical Group may only provide the telehealth services if you agree to this Informed Consent for Telehealth Services. This document supplements, but does not override, the Terms of Use, Privacy Policy, or Notice of Privacy Practices associated with Care for Hearts Medical Group and its Providers. 

By giving your Informed Consent for Telehealth Services, you acknowledge and agree to the risks, limitations, and benefits of telehealth services as described herein. Your continued use of the Platform and telehealth services signifies your ongoing acceptance of this consent and any updates We make to the Platform. 

About Care for Hearts

Care for Hearts is a medical practice providing cardiovascular health services exclusively through telehealth. Telehealth is a mode of delivering healthcare services through the use of telecommunications technologies, including asynchronous and synchronous technology, and remote patient monitoring technology, by a healthcare practitioner to a patient at a different physical location.

Our Services Include:

  • Cardiovascular disease management, including medication review and adherence counseling.
  • Analysis of your connected application data and, when available, certain of your medical or health record data provided via health information exchanges (HIE).
  • Care coordination with your healthcare providers.
  • Clinical reports published to HIE networks for your care team.

Our Care Model:

  • Providers conduct telehealth consultations.
  • Board-certified cardiologist clinical oversight.
  • Services delivered through secure platforms that are Health Insurance Portability and Accountability Act (HIPAA)-compliant.
  • When available, integration of multiple health data sources for comprehensive care.

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2. Benefits and Risks of Telehealth

Benefits:

  • Convenient access to specialized cardiovascular care from home or another location of your choosing.
  • Enhanced care coordination through data integration.
  • Reduced travel time and costs.
  • Health monitoring and medication support.

Limitations:

  • No physical examinations or hands-on evaluation.
  • Cannot address medical emergencies.
  • Requires reliable internet and compatible devices.
  • Some conditions may require in-person evaluation not offered by Care for Hearts Medical Group.

Technology Requirements:

  • Tablet or smartphone with camera/microphone.
  • Secure and stable internet connection.
  • Connected mobile application (e.g., Hello Heart’s mobile application).
  • Updated web browser or required telehealth applications.
  • Private, quiet environment for consultations.

Technical Issues:

  • You may experience internet or device connection problems.
  • You may experience technical failures.
  • You're responsible for data usage costs.

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3. Privacy, Security, and Health Information

HIPAA Compliance: We protect your health information according to HIPAA and state privacy laws through encrypted platforms, limited access controls, and secure data storage.

Information We Use:

  • Data and information obtained via connected mobile applications (e.g., blood pressure readings and self-reported data and information).
  • When available, certain medical records accessed through an HIE.
  • Consultation information.
  • Clinical assessments and recommendations.

Information Sharing:

  • Clinical information asynchronously shared among the Providers.
  • Clinical findings asynchronously shared with your healthcare providers through secure HIE networks.
  • Clinical and protected health information pursuant to HIPAA for treatment, payment, and healthcare operations purposes.
  • Disclosures as required by law, including for compliance investigations or enforcement; for public health activities; to law enforcement; for judicial and administrative proceedings; for specialized government functions (e.g., military, national security, correctional institutions); for worker’s compensation purposes.

Your Privacy Rights:

  • Access and copy your health records.
  • Request amendments to your information.
  • Request restrictions on information use.
  • File privacy complaints.

Security Responsibilities: 

It is your responsibility to 

  • Use secure, private networks.
  • Ensure privacy during consultations.
  • Protect your login credentials.
  • Report suspected security breaches.

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4. Emergency Procedures

⚠️ TELEHEALTH IS NOT FOR EMERGENCIES. CARE FOR HEARTS MEDICAL GROUP DOES NOT PROVIDE ANY EMERGENCY DIAGNOSIS, TREATMENT, OR GUIDANCE.

Call 911 immediately for:

  • Chest pain, heart attack, or stroke symptoms.
  • Severe breathing difficulties.
  • Loss of consciousness.
  • Severe allergic reactions.
  • Uncontrolled bleeding.
  • Suicidal thoughts.

For urgent non-emergency situations:

  • Contact your primary care physician.
  • Use urgent care centers.

Emergency Limitations:

  • We cannot provide emergency treatment.
  • We cannot prescribe emergency medications.
  • We cannot coordinate with emergency services.
  • We cannot replace in-person emergency evaluation.

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5. Rights and Responsibilities

Your Rights:

  • Receipt of quality telehealth care equivalent to in-person standards.
  • Receipt of clear information about your health and treatment options.
  • Privacy and confidentiality protection.
  • To withdraw your consent at any time.
  • To file complaints without retaliation.

Your Responsibilities:

  • Provide accurate health information.
  • Attend scheduled appointments or give adequate notice.
  • Use appropriate technology and private environment.
  • Follow treatment recommendations.
  • Seek emergency care when appropriate.

Provider Responsibilities:

  • Deliver care meeting professional standards.
  • Maintain current licensing and training.
  • Use secure, HIPAA-compliant technology.
  • Document interactions appropriately.

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6. Billing and Records

Insurance and Billing:

  • You must verify telehealth coverage with your insurance.
  • You are not billed for the Care for Hearts Medical Group services, as they are either covered by your health insurance or paid for by your employer.
  • You're responsible for applicable copayments, deductibles, and non-covered services.

Medical Records:

  • Electronic records are maintained for services.
  • Records are retained for a minimum of 7 years (or longer as required by state law).
  • You may access and request copies of your records.
  • Records shared through HIE networks as consented.

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By signing below, you acknowledge that you understand and agree with the following:

  1. You hereby consent to receiving the Care for Hearts Medical Group services via telehealth technologies, which could include communications through text messaging and mobile applications. You understand that the Care for Hearts Medical Group and the Providers offer telehealth-based medical services, but that these services do not replace the relationship between you and your primary care doctor, cardiologist, or other healthcare provider.  You also understand it is up to the Care for Hearts Medical Group providers to determine whether or not your specific clinical needs are appropriate for a telehealth encounter.
  2. You understand that federal and state law requires health care providers to protect the privacy and the security of health information.  You understand that the Care for Hearts Medical Group will take steps to make sure that your health information is not seen by anyone who should not see it. You understand that telehealth may involve electronic communication of your personal medical information to other health practitioners who may be located in other areas, including out of state.
  3. You understand there is a risk of technical failures during the telehealth encounter beyond the control of the Care for Hearts Medical Group. You agree to hold harmless the Care for Hearts Medical Group for delays in evaluation or for information lost due to such technical failures.
  4. You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time. You understand that you may suspend or terminate use of the telehealth services at any time for any reason or for no reason.  You understand that if you are experiencing a medical emergency, that you will be directed to dial 9-1-1 immediately and that the Care for Hearts Medical Group Providers are not able to connect you directly to any local emergency services.
  5. You understand that alternatives to telehealth consultation, such as in-person services, are available to you and may be required by other healthcare providers. By choosing to participate in Care for Hearts Medical Group telehealth consultations, you understand that you may be required to obtain services provided by individuals at your location, or at a testing facility, at the direction of the Care for Hearts Medical Group providers (e.g., labs or bloodwork).
  6. You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.
  7. You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes, for the coordination of care, and as otherwise required by law.
  8. You understand that you will not be prescribed any narcotics, nor is there any guarantee that you will be given a prescription at all.
  9. You understand that if you participate in a consultation, that you have the right to request a copy of your medical records which will be provided to you at reasonable cost of preparation, shipping and delivery. 
  10. You have read and you understand the disclosures set forth next to the state in which you are located at the time of the telehealth encounter, as set forth below: 

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STATE REGULATIONS:

Arizona: You understand that all medical records resulting from a telemedicine consultation are part of your medical record. (Ariz. Rev. Stat. Ann. § 36-3602(D)).

D.C.: You have been informed of alternate forms of communication between you and a physician for urgent matters.  (D.C. Mun. Regs. tit. 17, § 4618.10). Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record. (D.C. Mun. Regs. tit. 17, § 4618.9).

Georgia: You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment.  (Ga. Comp. R. & Regs. 360-3-.07(7)).

Indiana:  If a prescription is issued to you, and subject to your consent the prescriber shall notify your primary care provider of any prescriptions the prescriber has issued for you if the primary care provider's contact information is provided by you. This requirement does not apply if: (A) The practitioner is using an electronic health record system that your primary care provider is authorized to access. (B) The practitioner has established an ongoing provider-patient relationship with the patient by providing care to the patient at least 2 consecutive times through the use of telehealth services. If the conditions of this clause are met, the practitioner shall maintain a medical record for you and shall notify your primary care provider of any issued prescriptions. Ind. Code Ann. 25-1-9.5-7. 

Iowa: To file a complaint, fill in the form below or fill out the complaint form and email it to the medical board at ibmcomplaints@iowa.gov. Iowa Admin. Code 653-13.11(147,148,272C)(13.11(18)).

As appropriate your provider will identify the medical home or treating physician(s) for you, when available, where in-person services can be delivered in coordination with the telemedicine services. Your provider shall provide a copy of the medical record to your medical home or treating physician(s). Iowa Admin. Code 653-13.11(147,148,272C)(13.11(11))

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

https://kbml.ky.gov/board/Pages/default.aspx. 

Information related to filing grievances may be found here: https://kbml.ky.gov/grievances/Documents/Information%20on%20Filing%20A%20Grievance.pdf. Kentucky Board Opinion on the Use of Telemedicine Technologies (2014), as amended September 15, 2022.

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If requested by you, your physician must share the medical record with your primary care physician and other relevant members of your existing care team. Kentucky Board Opinion on the Use of Telemedicine Technologies (2014), as amended September 15, 2022.

Louisiana: You understand the role of other health care providers that may be present during the consultation other than the telehealth provider.  (46 La. Admin. Code Pt XLV, § 7511).

New Jersey:  You understand that you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers. If you do not have a primary care provider or other health care provider of record, the health care provider engaging in telemedicine or telehealth may advise you  to contact a primary care provider, and, upon request by you, may assist you with locating a primary care provider or other in-person medical assistance that, to the extent possible, located within reasonable proximity to you. N.J. Rev. Stat. Ann. § 45:1-62.

Ohio: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-37-01(C)(4).

Oregon: If you have a concern or complaint about the providers  providing care to you, you may contact a board agency to assist you. You understand that the provider may ask if you need more detail. ORS 17-52-677.07. See also Or. Medical Board, Statement of Philosophy: Telemedicine (Oct 2, 2020)

Complaints may be filed with:

Oregon Medical Board
1500 SW 1st Ave., Suite 620
Portland, OR 97201-5847

Complaint Resource Staff:  971-673-2702  |  complaintresource@omb.oregon.gov

South Carolina:  You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. You understand the value of having a primary care medical home and, if requested, We can provide assistance in identifying available options for a primary care medical home. S.C. Code Ann. § 40-47-37.

Texas: you understand that your medical records may be sent to your primary care physician within 72 hours. Tex. Occ. Code Ann. § 111.005. you have 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 our Website at www.tmb.state.tx.us.  

AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, 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: You are able to a (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services. Utah Admin. Code r. 156-1-602.

Virginia: You acknowledge that you have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; you agree to hold harmless the Care for Hearts Medical Group for information lost due to technical failures; and you provide your express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).