Piction Health Medical Group, P.A. (“Piction Medical”, “we”, “our” or “us”) provides tele-dermatology services (the “Care Team”) with support from its technology partner, Piction Health, Inc. (“Piction Health”). This Agreement describes Piction Medical’s services and clinical programs. It is important for you to read this document and discuss any questions you might have with us.
Our Services and Technology
Our program is designed to empower you to take control of your health and access quality dermatology care from home. When you or your child becomes a patient of Piction Medical (a “Member”), you will be given access to the mobile or desktop application of Piction Health (the “Piction App”) and our Care Team. The Piction App provides personalized content and interactive resources for you, simple tools for billing, serves as your hub of information including medical and imaging records, and connects you to our Care Team. Your Care Team will be with you every step of the way and work collectively to support high quality, effective care.
Scheduling and Attendance
We understand you may have to reschedule or cancel an appointment from time to time. We ask that you notify us at least 24 hours in advance of your scheduled appointment. If you repeatedly miss scheduled appointments, and if Piction Medical is unable to contact you for a period of time, you understand that you may be terminated from the program and no longer have access to your Piction Care Team.
Telehealth Informed Consent - Risks and Benefits
Your Care team will provide medical care via telehealth using voice calls, video calls and messaging services. They may prescribe you medication or recommend other treatment, as needed. Telehealth care is a flexible and convenient way to get healthcare, but it may not be right for treating certain symptoms or illnesses that need an in-person doctor or urgent care visit. If you are having a medical emergency, call 9-1-1 or go to the nearest emergency room.
All laws and protections for in-person medical visits also apply to telehealth visits. This includes confidentiality of information, access to medical records, and sharing of information that could identify you personally.
You have a right to know who is attending each telehealth visit. You may decide that you do not want to use telehealth services at any time. This will not make you lose your health program benefits or your rights to future health care.
Telehealth services are convenient and offer better access to health care. However, as with any health service, there are potential risks associated with using technology. These risks include service problems due to technology or internet failures, not having enough information to make health care decisions, rare security errors, and other risks. You agree to take on the risk for information lost due to technology problems.
Video and Audio Recordings
With permission, in certain cases, we may make video or audio recordings of your telehealth session. Those recordings will be used internally for treatment, quality improvement and care coordination purposes in accordance with our privacy policies.
Payment and Billing
Your submission of credit card information, in conjunction with your agreement of this Informed Consent, authorizes us to charge the credit card on file for agreed upon purchases. By signing this agreement, you agree to pay amounts you owe to Piction Medical in accordance with our payment policies. If you qualify for benefits from any insurance company(s) or health plan(s), by signing this agreement, you are also agreeing to: (i) assign those benefits to Piction Medical to pay for care provided, (ii) sign any additional forms required by any insurance company or health plan (each a “Payor”) to confirm this assignment of benefits, and (iii) authorize Piction Medical to release all relevant information about your health care necessary to receive payment from the applicable Payor.
If you have any remaining questions about your financial responsibility or assignment of benefits, it is important that you discuss these questions by contacting email@example.com.
We must follow federal healthcare privacy and security laws and protect your health information. We work hard to make sure that your personal information is secure. We use standard physical, electronic, and business security methods (such as encryption) to help prevent access to your health information by people who should not see it. But we cannot promise that data sent over the Internet or through a data storage facility will be perfectly secure. So, although we try to protect your personal information, we cannot guarantee the security of any information you send to us. You can read more information about our use of health information and other personal information in our Notice of Health Information Privacy Practices (“NPP”).
We may share your health records with the following individuals under the following circumstances:
1. With your other health care providers, either directly or through our participation in health information exchanges, for healthcare coordination, operations and treatment purposes. This may include information relating to genetic tests, substance abuse, mental health, communicable diseases and other health conditions
2. With other individuals involved in your care such as caregivers or family members.
3. As otherwise permitted in our Notice of Privacy Practices and by applicable law.
By signing below, you agree to let us share your records as described above and acknowledge receipt of the Notice of Privacy Practices.
As part of providing services, we may communicate with you, including for purposes such as appointment reminders and announcements. If you have provided us with a cell phone number and email address, we may send you SMS text messages and emails. Text messages and emails are not always secure because they travel over networks that we do not control.
By signing below and providing us your cell phone number and email address, you permit us to contact you by SMS text message and email. You may also ask us to stop by contacting your Care Team. You understand that you may have to pay data costs to receive SMS text messages that we send to your mobile phone.
All Members have the right to communicate grievances regarding their care. Should you wish to make a formal complaint about one of your care providers you may do so in writing and submit the concern to Piction Medical at firstname.lastname@example.org.
[Additional State Specific Disclosures]
The following disclosures apply to Members accessing the Piction App for the purposes of participating in a telehealth visit as required by the states listed below:
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: https://medicalboard.iowa.gov/consumers/filing-complaint.
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: https://kbml.ky.gov/grievances/Pages/default.aspx.
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: https://www.maine.gov/md/complaint/file-complaint.
New York: I have been informed that to get information regarding your rights and how to report professional misconduct, I should visit, here: https://www.health.ny.gov/professionals/doctors/conduct.
Oregon: 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: https://www.oregon.gov/omb/investigations/pages/how-to-file-a-complaint.aspx.
Rhode Island: 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: https://health.ri.gov/complaints/.
Texas: I 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
Vermont: 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: http://www.healthvermont.gov/health-professionals-systems/board-medical-practice/file-complaint; or Board of Osteopathic Examiners can be found at: https://sos.vermont.gov/opr/complaints-conduct-discipline/
Wyoming: 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: http://wyomedboard.wyo.gov/consumers/file-a-complaint.]
Agreement and Consent
If you have questions about any of the contents of this clinical services agreement, our procedures, or your role in this process, please discuss them with your Care Team. Remember that the best way to assure quality treatment is to keep communication open and direct with your clinician(s).
By filling out the patient intake form you indicate that you have read and understood this document, and that you agree to abide by its terms. Further, you certify that if you are signing as a personal representative of the Member, you have legal authority to provide consent for the treatment of the Member.