Clinical Services Agreement and Telehealth Informed Consent

Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care.  This “Clinical Services Agreement and Telehealth Informed Consent” informs the patient (“patient,” “you,” or “your”) concerning the treatment methods, risks, and limitations of using a telehealth platform.  

Services Provided:

Telehealth services offered by Park Hill Health Services, P.A., Park Hill Health Services of New Jersey, P.C., and Richard Joseph, M.D., P.C. (“Group” or “Park Hill”), and the Group’s engaged providers (our “Providers” or your “Provider”) may include a patient consultation, diagnosis, treatment recommendation, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services”).  

Enduring Management Services, LLC, dba “Miga” does not provide the Services; it performs administrative, technology, payment, and other supportive activities for the Group and our Providers.

When you become a patient of the Group (“Member”), you will be given access to the online Miga platform (“Platform”). Group provides healthcare services related to heart health via the Platform. The Platform provides personalized content and interactive resources for you, simple tools for scheduling appointments and billing, serves as your hub of information, and connects you to our Providers.

For purposes of this Clinical Services Agreement and Telehealth Informed Consent, “you” means you as the patient, or as the lawful guardian, conservator, or custodian on behalf of your family member (“Family Member”) to the extent you are agreeing to this Clinical Services Agreement and Telehealth Informed Consent on behalf of a Family Member.

Electronic Transmissions:

The types of electronic transmissions that may occur using the telehealth platform include, but are not limited to:

Appointment scheduling;

Completion, exchange, and review of medical intake forms and other clinically relevant information (for example: health records; images; output data from medical devices; sound and video files; diagnostic and/or lab test results) between you and your Provider via:

* asynchronous communications (e.g. text messages);

* two-way interactive audio in combination with store-and-forward communications; and/or

* two-way interactive audio and video interaction;

Treatment recommendations by your Provider based upon such review and exchange of clinical information;

Delivery of a consultation report with a diagnosis, treatment and/or prescription recommendations, as deemed clinically relevant;

Communications and exchange of information with your health plan (if applicable);

Communications and exchange of information with your other providers (if applicable);

Prescription refill reminders (if applicable); and/or

Other electronic transmissions for the purpose of rendering clinical care to you.

Remote Patient Monitoring:

For many of our clinical programs, we will provide you with remote devices and equipment so that we can remotely monitor clinical and physiological data relating to your health on an ongoing basis as provided in your treatment plan (collectively “Remote Patient Monitoring” or“RPM”) and provide you with telehealth services.  Remote PatientMonitoring helps us more quickly and proactively assess your clinical needs and make recommendations aimed at improving your health.  RPM services are not emergency services, and your data will not be monitored 24/7. If you are responsible for paying a deductible, copayment or coinsurance for your health care, the usual cost-sharing rules will apply for RPM services.

By agreeing to this Clinical Services Agreement and Telehealth Informed Consent, you are authorizing us to provide you with RPM services.

RPM Disclaimers:

You are the only person who should be using the remote monitoring equipment as instructed.

You will not use the device for reasons other than your own personal health monitoring.

You can only participate in this program with one medical provider at a time.

You will not tamper with the equipment.

You are responsible for any fees associated with misuse of the equipment.

You will use the equipment at least 16 days per month.

You may be asked to return the equipment to Miga.

The devices are only designed for the Miga RPM program.

Miga and Park Hill are not responsible for inaccuracies in data recorded in the RPM equipment.

Chronic Care Management:

We are committed to providing comprehensive care to help you manage your health effectively. As part of our commitment, we offer Principal Care Management (PCM) and Chronic Care Management (CCM) services. These services are designed to support patients with chronic conditions through regular monitoring, care coordination, and personalized health plans.

PCM and CCM can help us work with your other clinicians to improve your health. If you do not think you need PCM or CCM, you can ask us to stop at any time. Only one healthcare provider or facility can provide PCM or CCM services and be paid for these services during a calendar month.

By agreeing to this consent, you agree to use PCM or CCM services with your Provider. If you have to pay a deductible, copayment or coinsurance for your healthcare, the usual cost-sharing rules will apply. You may stop using PCM or CCM services at any time at the end of the calendar month by sending us a message asking us to stop using PCM or CCM.

Expected Benefits:

Improved access to care by enabling you to remain in your preferred location while your Provider consults with you.  Our telehealth services are available from 9am - 5pm ET, five days a week (Monday - Friday).

Convenient access to follow-up care.  If you need to receive non-emergent follow-up care related to your health condition, please send a direct message to your Provider.  

More efficient care evaluation and management.

Service Limitations:

The primary difference between telehealth and direct in-person service delivery is the inability to have direct, physical contact with the patient. Accordingly, some clinical needs may not be appropriate for a telehealth visit and your Provider will make that determination.

OUR PROVIDERS DO NOT ADDRESS MEDICAL EMERGENCIES. IFYOU BELIEVE YOU ARE EXPERIENCING A MEDICAL EMERGENCY, YOU SHOULD DIAL 9-1-1AND/OR GO TO THE NEAREST EMERGENCY ROOM. PLEASE DO NOT ATTEMPT TO CONTACT MIGA, GROUP, OR YOUR PROVIDER.  AFTER RECEIVING EMERGENCY HEALTHCARE TREATMENT, YOU SHOULD VISIT YOUR LOCAL PRIMARY CARE PROVIDER.

Our Providers are an addition to, and not a replacement for, your local primary care provider.  Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not.

Group does not have any in-person clinic locations.

Privacy and Security Measures:

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. All the Services delivered to the patient through telehealth will be delivered over a secure connection that complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). However, 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 agree we may share your health records with the following individuals under the following circumstances:

With your other health care providers (including your primary care provider), either directly or through our participation in health information exchanges, and for healthcare coordination, operations and treatment purposes. This may include information relating to genetic tests, substance use, mental health, communicable diseases and other health conditions.

With other individuals involved in your care such as caregivers or family members.  

With your health plan, either directly or through our participation in health information exchanges, and for healthcare coordination, operations and treatment purposes (such as eligibility verification and audits of our services). This may include information relating to genetic testing, substance use, mental health, communicable diseases and other health conditions.

As otherwise permitted in our Health Information Privacy Practices and by applicable law.  

By attesting to this consent, you agree to let us share your records as described.

Possible Risks: 

Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies, or provider availability.

In the event of an inability to communicate as a result of a technological or equipment failure or other followup care, please contact the Group at 510-722-5630 or support@migahealth.com.

In rare events, your Provider may determine that the transmitted information is of inadequate quality or that Provider does not have enough information to make healthcare decisions, thus necessitating a rescheduled telehealth consult or an in-person meeting with your local primary care doctor.

In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

Payment and Billing:

You understand that if your health insurance (including Medicare) coverage does not cover the charges for your services in full or at all, you may be fully or partially responsible for payment. If your health insurance requires you to pay a deductible, copayment or coinsurance for your healthcare, the usual cost-sharing rules will apply.  Please check with your health plan to determine if any services will be reimbursed.  If you request, we will work with you to determine what your charges will be. If you are paying for your visit without insurance, we will inform you of any amounts owed.

You authorize and agree that Medicare, health plans and any other persons or organization (third parties) who pay any part of your Group bill are authorized to pay these amounts directly to us (instead of you) for medical treatment by Group. In the event an insurance payer pays you directly, you agree to immediately pay such amounts to Group. You agree that we may submit claims to these third parties on your behalf. You understand that you must pay us for services we provide that are not paid by your insurance or other third parties (“Your Costs”), unless state or federal regulations do not allow this. This assignment will remain in effect until revoked in writing.

You authorize the release of pertinent information necessary to process your medical claim.

You understand that if your insurance requires a referral, you are responsible for obtaining one prior to your appointment.  In the event any collection action is necessary to collect amounts you owe to Group, you agree to pay all expenses associated with such action, including but not limited to collection agency fees and attorneys’ fees.  

We accept credit and debit cards issued by U.S. banks. If a credit card account is being used for a transaction, we may obtain pre approval for an amount up to the amount of the payment. If you enroll to make recurring payments automatically, all charges and fees will be billed to the credit card you designate during the setup process. If you want to designate a different credit card or if there is a change in your credit card, you must change your information online. This may temporarily delay your ability to make online payments while we verify your new payment information.

By certifying to this Clinical Services Agreement and Telehealth Informed Consent, you hereby assign to Group all right, title, and interest in any and all health insurance or other health care benefits payable to you or on your behalf by any insurance pay or for any medical treatment rendered by Group.

Visit Cancellation / No Show Policy and Fee:

When you schedule an appointment with Park Hill, we set aside enough time to provide you with the highest quality care. Should you need to cancel or reschedule an appointment, please contact us as soon as possible, and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointment. Any patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours notice will be considered a No Show and charged a cancellation fee.

Consent to Receive Text Messages and Emails:

From time to time, we may provide you with messages such as appointment reminders, service announcements, privacy notices, administrative messages, and other communications relating to your care.  This may include SMS text messages and emails.  Text messages and emails are not always secure because they travel over networks that we do not control.  By attesting to this consent, you are authorizing us to send you SMS text messages and emails.

Message and data rates may apply. To stop receiving text messages, text a reply to us with the word STOP. We may confirm your opt out by text message. If you subscribe to multiple types of text messages from us, we may unsubscribe you from the service that most recently sent you a message or respond to your STOP message by texting you a request to identify which services you wish to stop. Please note, that by withdrawing your consent, some of the functions provided by the Platform may no longer be available to you. Keep in mind that if you stop receiving text messages from us you may not receive important and helpful information and reminders about your services.

Patient Acknowledgments:

By agreeing to all of the terms set forth in this Clinical Services Agreement and Telehealth Informed Consent, you acknowledge your understanding and agreement to the following:

1. Prior to the telehealth visit, I will be given an opportunity to select a provider as appropriate, including a review of the provider’s credentials, or I have elected to visit with the next available provider from Group, and have been given my Provider’s credentials.

2. If I am experiencing a medical emergency, I will be directed to dial 9-1-1 immediately and my Provider is not able to connect me directly to any local emergency services.

3. I may elect to seek services from a medical group with in-person clinics as an alternative to receiving telehealth services.

4. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time without affecting my right to future care or treatment.

5. Federal and state law requires health care providers to protect the privacy and the security of health information.  I am entitled to all confidentiality protections under applicable federal and state laws.  I understand all medical reports resulting from the telehealth visit are part of my medical record.  

6. Group will take steps to make sure that my health information is not seen by anyone who should not see it. Telehealth may involve electronic communication of my personal health information to other health practitioners who may be located in other areas, including out of state. I consent to Group using and disclosing my health information for purposes of my treatment (e.g., prescription information) and care coordination, to receive reimbursement for the services provided to me, and for Group’s health care operations.

7. Dissemination of any patient-identifiable images or information from the telehealth visit to researchers or other educational entities will not occur without my consent unless authorized by state or federal law.

8. There is a risk of technical failures during the telehealth visit beyond the control of the Group.  

9. In choosing to participate in a telehealth visit, I understand that some parts of the Services involving tests (e.g., labs or bloodwork) may be conducted at another location such as a testing facility, at the direction of my Provider.

10. Persons may be present during the telehealth visit other than my Provider who will be participating in, observing, or listening to my consultation with my Provider (e.g., in order to operate the telehealth technologies). If another person is present during the telehealth visit, I will be informed of the individual’s presence and his/her role.

11. My Provider will explain my diagnosis and its evidentiary basis, and the risks and benefits of various treatment options.  

12. I understand that by creating a treatment plan for me, my Provider has reviewed my medical history and clinical information and, in my Provider’s professional assessment, has made the determination that the provider is able to meet the same standard of care as if the health care services were provided in-person when using the selected telehealth technologies, including but not limited to, asynchronous store-and-forward technology.

13. I have the right to request a copy of my medical records.  I can request to obtain or send a copy of my medical records to my primary care or other designated health care provider by contacting Miga, on behalf of the Group at: 510-722-5630 or support@migahealth.com. A copy will be provided to me at a reasonable cost of preparation, shipping and delivery.  

14. It is necessary to provide my Provider a complete, accurate, and current medical history.  I understand that I can reach out to my provider at any time to access, amend, or review my health information.

15. There is no guarantee that I will be issued a prescription and that the decision of whether a prescription is appropriate will be made in the professional judgment of my Provider.  If my Provider issues a prescription, I have the right to select the pharmacy of my choice.

16. There is no guarantee that I will be treated by a Group provider. My Provider reserves the right to deny care for potential misuse of the Services or for any other reason if, in the professional judgment of my Provider, the provision of the Services is not medically or ethically appropriate.

*If you are agreeing to this Clinical Services Agreement and Telehealth Informed Consent on behalf of a Member who is a family member or otherwise under your legal guardianship, you certify that you have legal authority to provide consent for the treatment of the Member. You also agree to provide, if we make a request, a copy of the most recent power of attorney that demonstrates that you have the right to authorize care and treatment for the Member.  If there are any changes in your legal status with respect to the Member, you understand that it is your responsibility to promptly notify us of any such changes.  Please be aware that our patient is the Member – not the personal representative nor any other family members of the Member.

Additional State-Specific Consents: The following consents apply to patients accessing Group’s website for the purposes of participating in a telehealth consultation as required by the states listed below:

Alaska: 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.

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.

Idaho:  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.

Indiana:  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.

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.

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; Or, the Maine Board of Osteopathic Licensure’s website, here.

Oklahoma: 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; Or, the Oklahoma Board of Osteopathic Examiners’ website, here.

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.

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.

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; Or, the Vermont Board of Osteopathic Examiners’ website, here.

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