by using our service you agree to policies and TOS listed below:
What information do we collect and why?
Your Personal Information may be used for the following purposes:
- To provide you with information regarding how to access our services.
- To contact you or provide you with information, alerts and suggestions that are related to our services.
- Billing-related purposes.
- To reach out to you, either ourselves or using the appropriate authorities, if we have a good reason to believe that you or any other person may be in danger or may be either the cause or the victim of a criminal act.
How can you protect your information?
Online identity theft and account hacking, including the practice currently known as “phishing”, are of great concern. We will never request your login information for Kareo, VSee, or any other third party we use, or your credit card information in any non-secure or unsolicited communication such as email or telephone. If you receive an email or phone call requesting this information, please contact Kareo or VSee, depending on the information requested. If you receive a request for information via email or phone that appears to be from Alphatelemed.com, please contact us at firstname.lastname@example.org.
- Third Party Sites
- How do we protect the information you provide to us?
While using any Internet-based service carries inherent security risks, we do our best to protect the information you provide to us via the Site (your name and email). However, we cannot guarantee 100% security of your information.
While we do not collect information protected health information (PHI) via the Site, we have chosen partners (Kareo and VSee) to collect this information that have assured us they will protect the information that you provide to them and they will comply with all applicable federal and state laws, including HIPAA. However, because we do not control their privacy or security practices, as described in Section 5 above, Alphatelemed.com is not responsible for any unauthorized disclosure or breach of your information that you submit via those third-party sites.
- Additional Third-Party Service Providers
In addition to VSee and Kareo, we may employ other third party companies and individuals to facilitate our Site, to perform certain tasks which are related to the Site, or to provide audit, legal, operational or other services for us. These tasks include without limitation customer service, technical maintenance, monitoring, email management and communication, database management, billing and payment processing, reporting and analytics. We will share with them only the minimum necessary information to perform their task for us and only after entering into appropriate confidentiality agreements.
- Children’s Privacy
We do not knowingly collect or solicit any information from anyone under the age of 13 or knowingly allow such persons to become our user. The Site is not directed and not intended to be used by children under the age of 13. If you’re aware that we have collected Personal Information from a child under the age of 13 please contact us at email@example.com.
- International Transfer
Your information may be transferred to — and maintained on — computers located outside of your state, province, country or other governmental jurisdiction. Regardless of where your data is stored, it will be maintained securely as outlined in this policy. Your consent to our Terms and Conditions followed by your submission of such information represents your agreement to such transfers.
- We Cooperate With Government and Law Enforcement
We cooperate with government and law enforcement officials to enforce and comply with the law. We may disclose information necessary or appropriate to protect the safety of the public or any person, to respond to claims and legal process (including but not limited to subpoenas), and to prevent or stop activity that may be illegal or dangerous. You should also be aware that your provider may be obliged to disclose information to law enforcement or other authorities to conform to their professional and legal responsibilities. Specifically, and without limitation, you should be aware that the law requires mental health professionals to disclose information and/or take action in the following cases: (a) reported or suspected abuse of a child or vulnerable adult; (b) serious suicidal potential; (c) threatened harm to another person; (d) court-ordered presentation of treatment.
- Contacting us
Informed Consent to Services Performed by Alphatelemed.com (Alpha Healthcare Services and Solutions LLC DBA Alphatelemed.com).
Hello, and Welcome! This document contains important information about our telehealth/telemedicine services and policies. Please read the following closely and raise any questions you may have with your provider prior to signing.
What is Telehealth?
Telehealth involves the use of two-way, telecommunications technology, such as video-chat, whereby a clinician renders healthcare services from one location to a patient who is located at another location. Such clinicians may include physicians, counselors, nurse practitioners, therapists, and others. Telehealth services may include diagnosis, consultation, treatment, counseling services, education, care coordination, and other healthcare services.
Benefits & Risks
The provision of services via telehealth technology presents risks that may arise, despite reasonable efforts on the part of Alphatelemed.com. However, there are also key benefits to telehealth services. We encourage you to consider these risks and benefits before agreeing to receive services through us.
· Improved access to services by enabling the patient to connect with clinicians remotely from the comfort of the patient’s home
· Eliminating transportation barriers
· Eliminating or shortening appointment wait times
· Improved access to care through the availability of a wide range of experts
· Increased capacity of clinicians to devote time to patients
· More efficient care management and care coordination
· Increased efficiency and convenience of use—including online scheduling and communication with counselors
· Improved team treatment model through virtual collaboration
· Improved psychosocial and satisfaction outcomes for patients
· Providing an alternative to in-person interaction for patients who otherwise might be resistant to seeking in-person care in a clinic setting
· In rare cases, information transmitted through telecommunications technology may not be sufficient to allow for appropriate clinical decision-making.
· Delays in clinical evaluation and treatment could occur due to deficiencies or failures of the equipment or connections.
· In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
· You compromise your own confidentiality if you do not place yourself in a private area.
Alternatives to Alphatelemed.com
If you prefer not to receive services virtually, Alphatelemed.com may be able to provide you with an opportunity to receive in-person services, depending on availability, or we may refer you to a different provider.
Privacy and Security
Alphatelemed.com DOES NOT provide emergency healthcare services. If, at any time, you believe you are experiencing a medical emergency or other health-related crisis, call 911 or go to the nearest emergency room. If you experience suicidal thoughts or plans to harm yourself, you may also contact your local crisis center or call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free, 24/7 hotline support.
Alphatelemed.com provides non-emergency, telehealth and in-person services by scheduled appointment. Our clinicians are not available on a 24-hour basis and may not be available on demand. If an Alphatelemed.com clinician determines that your healthcare needs are outside of scope of our practice, we are legally obligated to refer you to another provider.
Alphatelemed.com has a strict “No Recording” policy. You may not record any of your sessions, whether they take place in person or via telehealth, without your provider’s consent.
By signing this consent form, I acknowledge and agree that I have read and understood the above disclosures. I further understand and agree that:
- I have the option to withhold my consent to receive services at this time or to withdraw this consent at any time, including at any point during an appointment, without affecting my right to future care, treatment, or risking the loss or withdraw of any program benefits to which I would otherwise be entitled.
- I may expect the anticipated benefits from the use of telemedicine in my care but that no results can be guaranteed or assured.
- I will not record any visits with my provider, whether they take place in person or via telehealth.
- There are potential risks associated with telehealth services, including, but not limited to, the possibility, despite reasonable efforts on the part of Alphatelemed.com and its clinicians, that the transmission of my personally identifiable information could be disrupted or distorted by technical failures; the transmission of my personally identifiable information could be intercepted by unauthorized persons; and/or the electronic storage of my personally identifiable information could be accessed by unauthorized persons. Although Alphatelemed.com takes steps to ensure the confidentiality and privacy of virtual communications, these actions, in whole or in part, cannot guarantee the security of online transmissions. I am solely responsible for ensuring the privacy of my surroundings when receiving services from Alphatelemed.com.
- If my Alphatelemed.com clinician believes I would be better served by another type or means of services (e.g., in-person services), I may be referred to a provider of such services in my area.
- There are potential risks and benefits associated with any form of healthcare services and that, despite my efforts and the efforts of my clinician, my condition may not improve and, in some cases, may worsen.
- There are alternative means of accessing Alphatelemed.com services, and I may choose one or more of these alternatives at any time. Alphatelemed.com has explained the available alternatives to my satisfaction.
- It is my responsibility to ensure the privacy and security of Alphatelemed.com information or records stored on or accessible by any device I may use in the course of receiving Alphatelemed.com services (e.g., computer, smartphone).
- Neither I nor my attorney will call on my clinician to testify in court or at any other legal or administrative proceeding.
I am free to refuse services at any time, and I have the right to terminate treatment at any time.
I understand that I will not conduct video visits while driving or any unsafe location. It is illegal and dangerous. The provider cannot conduct the appointment in any unsafe environment.
I understand I will provide a physical address in Virginia and P.O. are not acceptable for Telehealth/Telemedicine practice.
Authorization and Consent for Treatment:
Assignment of Benefits and Authorization to Release Medical Information
I authorize and understand that payment of benefits under Medicare, Medicaid, and/or any other insurance company, will be made on my behalf to the provider, for services furnished to me by that provider. I authorize any holder of my medical information to release it to Alphatelemed.com division of Alpha Healthcare Services and Solutions LLC, the Health Care Financing Administration, listed insured and/or agents of the company and/or the listed responsible person(s), any information needed to determine these benefits or the benefit for the related services. In the event that my insurance plan is out of the to Alphatelemed.com division of Alpha Healthcare Services and Solutions LLC network, or if I am a self-pay patient, assignment of benefits may not apply. I certify that the information I have reported with my insurance coverage and demographics is correct.
I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by either me or my insurance company at any time in writing.
As a component of my care, I understand and agree that Alphatelemed.com division of Alpha Healthcare Services and Solutions LLC may contact me using phone calls, text messages to my landline or calls and emails sent to my mobile device. These communications may notify me of test results, treatment recommendations, outstanding balances, or any other communication from the medical group.
Patient Financial Obligation Agreement:
I understand and agree that all applicable co-payments and deductibles are due at the time of service. I agree to be financially responsible and make full payment for all charges not covered by my insurance company. I authorize my insurance benefits be paid directly to Alphatelemed.com for services rendered. I authorize representatives of Alphatelemed.com to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim.
All visits are by appointment only:
Unless your follow-up appointment has been scheduled for you during your session, it is your responsibility to schedule (and reschedule as necessary) follow-up appointments through the patient portal. Outside of exceptional circumstances, where you are unable to access the patient portal or use email, please do not call the clinic for appointment inquiries, changes, or cancellations.
Cancellations and rescheduling of follow-up appointments should be made at least 24 business hours in advance by calling or texting. Failure to do so will result in additional charges as follows:
No Show/late cancellation (less than 24 hours in advance): $50 fee self/pay not billable to insurance.
If your provider at Alphatelemed.com prescribe a controlled medication, you must read and agree to the following policy. Controlled medicine can be dangerous and habit forming. These medicines must be taken only as prescribed by your doctor. Please read this consent and agreement thoroughly and ask any questions you may have.
If you are in agreement and fully understand the benefits and risks of the medications, sign and date below:
• I understand that the medication I am being prescribed may cause addiction, but my provider feels it is necessary for treatment of my condition. My provider has explained to me the potential risks, the potential short and long term side effects; the risk of drug interactions and over-sedation; the risk of misuse
and overdose. I accept these risks.
• I agree to take this medication only as prescribed by my provider.
• I agree to attend all scheduled appointments with my provider, NP or Medical Assistant.
• I understand that refills will not be given early.
• I will not obtain controlled substances from any other providers unless authorized by my primary prescriber, because it may be considered illegal to obtain controlled substances from multiple providers. • I understand that these medications are for my personal use only.
• I understand that it is illegal, and can be reported to the police, to give or sell my medication to others. • I agree to not use any illegal substances, including but not limited to marijuana, cocaine, or any other “street drugs”.
• I understand that it is illegal for me to use medications that are not prescribed to me.
• I understand that I am responsible for my own medication. Lost or stolen medication will not be replaced.
• I give up the right to privacy protections with regard to my prescription for controlled substances. The provider or his staff may talk with other providers, pharmacists or family members to confirm appropriate medication use.
• I agree to submit to random drug screening tests when ordered by my provider, and I will be responsible for payment for the tests.
• If requested of me, I agree to bring my medication bottle(s) to the office for the purpose of a pill count.
• I understand that I may obtain my controlled substances from only one pharmacy and it will be in VIRGINIA, and I agree to update my provider’s office of any changes in the pharmacy I use.
• I understand these medications may interfere with my ability to drive and/or operate heavy machinery.
• I understand this agreement is entered the date it is signed and completed.
• I have reviewed this Informed Consent and Treatment Agreement for Controlled Substances. I understand it and continue to agree to honor the Agreement. I understand that failure to do so may result in my discharge from this medical practice.