Thank you for choosing Nurojoy, LLC (Nurojoy) and Beluga Health, P.A. (“Beluga”). You are viewing this form because you have elected to engage in asynchronous telemedicine visits with a Beluga healthcare practitioner via Nurojoy. Your practitioner is a board-certified physician licensed in your state.
By clicking “I Agree,” I ACKNOWLEDGE I HAVE READ AND UNDERSTAND THE TERMS PRESENTED BELOW, AND UNDERSTAND THE RISKS AND BENEFITS OF ASYNCHRONOUS TELEMEDICINE, AND BY ACCEPTING THESE TERMS OF USE I HEREBY GIVE MY INFORMED CONSENT TO PARTICIPATE IN ASYNCHRONOUS TELEMEDICINE UNDER THESE TERMS.
What is Telemedicine?
Telemedicine is the delivery of healthcare services, including examination, consultation, diagnosis, and treatment, through electronic communication technologies when you (the patient) are located in a different location than your healthcare practitioner. Beluga allows you to receive treatment from a healthcare practitioner without having to travel to another location or schedule a separate appointment and helps you avoid long wait times that you might otherwise experience at an in-person visit.
What is Asynchronous Telemedicine?
Asynchronous telemedicine is one way to deliver telemedicine. Asynchronous communication is often referred to as “store-and-forward” communication, where participants submit and collect data at different times. An example of asynchronous communication is a telemedicine encounter with a healthcare practitioner that involves sending photos, video, or other communications via email or text message. “Asynchronous” means “not occurring at the same time” and is different from “synchronous” telemedicine, which generally includes visits conducted in real-time between patients and healthcare practitioners through audio or video means (e.g., live phone calls or video-conferencing). Healthcare practitioners may use asynchronous telemedicine to aid in diagnoses and medical consultations when live communication or face-to-face contact is not possible or necessary.
Beluga’s platform (“Platform”), in particular, allows for the following asynchronous telemedicine services: 1) text-based healthcare practitioner-patient interactions through short message service (“SMS”) and multimedia messaging service (“MMS”) communications; and 2) secure information collection through asynchronous store-and-forward patient questionnaires.
What are the Possible Risks to Using Asynchronous Telemedicine?
As with any medical treatment, there are potential risks associated with the use of asynchronous telemedicine. Beluga believes that the likelihood of these risks materializing is very low.
These risks may include, without limitation, the following:
• Delays in medical evaluation and consultation or treatment may occur due to deficiencies or failures of the equipment or the Internet, which may include poor data quality, Internet outages, or other service interruption issues. You may reschedule the visit with your healthcare practitioner should these interruptions occur.
• Security protocols could fail, causing a breach of privacy of personal medical information.
• Because Beluga does not have access to your complete medical records, if you do not disclose to your healthcare practitioner a full list of your medical history including diagnoses, treatments, medications/supplements, and allergies, adverse treatment, drug interactions or allergic reactions, or other negative outcomes may occur.
• Asynchronous telemedicine services are NOT emergency services and your Personal Data (as defined in the Beluga Privacy Policy) WILL NOT BE MONITORED 24/7. If you think you are experiencing a medical emergency, CALL 911 IMMEDIATELY.
THE CARE YOU RECEIVE WILL BE AT THE SOLE DISCRETION OF THE HEALTHCARE PRACTITIONER WHO IS TREATING YOU, WITH NO GUARANTEE OF DIAGNOSIS, TREATMENT, OR PRESCRIPTION. THE HEALTHCARE PRACTITIONER WILL DETERMINE WHETHER OR NOT THE CONDITION BEING DIAGNOSED AND/OR TREATED IS APPROPRIATE FOR THE CARE PROVIDED THROUGH AN ASYNCHRONOUS TELEMEDICINE ENCOUNTER VIA THE PLATFORM.
Your Rights and Acknowledgements:
• You have the same privacy rights via asynchronous telemedicine that you would have during an in-person visit. Dissemination of any identifiable images or information from the asynchronous telemedicine visit to researchers or other entities will not occur without your written consent. For more information about how we protect your privacy, please read the Beluga Privacy Policy here
• Asynchronous telemedicine may involve electronic communication of your personal medical information to healthcare practitioners who may be located in other areas, including out of state.
• You understand that you may expect the anticipated benefits from the use of asynchronous telemedicine, but that no results can be guaranteed or assured.
• You understand that all information submitted to Beluga via text message and entered by your healthcare practitioner in the Beluga Platform will be part of your medical record and available to you by emailing admin@belugahealth.com. This information will have the same restrictions on dissemination without your consent.
• You understand that your healthcare practitioner’s initial text message to you will include his/her name and credentials, and this will be recorded in the Beluga Platform as part of your medical record.
• You understand you may withdraw your consent and delete your patient profile at any time by emailing admin@belugahealth.com.
PROTECTED HEALTH INFORMATION
This Notice of Privacy Practices ("Notice") describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment, payment, or healthcare operations and for other purposes that are permitted or required by law. This Notice also describes your rights regarding your PHI. We are required by law to maintain the privacy of your PHI, provide you with this Notice of our legal duties and privacy practices, and to abide by the terms of this Notice.
Uses and Disclosures of PHI
We may use and disclose your PHI for the following purposes:
a. Treatment: We may use and disclose your PHI to provide, coordinate, or manage your healthcare and related services. This may include communication with other healthcare providers about your treatment and coordinating your care with other providers.
b. Payment: We may use and disclose your PHI to obtain payment for healthcare services provided to you. This may include contacting your insurance company to verify your coverage, billing and collection activities, and sharing PHI with other healthcare providers, insurance companies, or collection agencies.
c. Healthcare Operations: We may use and disclose your PHI for healthcare operations, including quality assessment, improvement activities, case management, accreditation, licensing, credentialing, and conducting or arranging for medical reviews, audits, or legal services.
d. As Required by Law: We may use and disclose your PHI when required to do so by federal, state, or local law.
e. Public Health and Safety: We may use and disclose your PHI to prevent or control disease, injury, or disability, to report child abuse or neglect, to report reactions to medications or problems with products, and to notify persons who may have been exposed to a communicable disease or may be at risk of spreading a disease or condition.
f. Health Oversight Activities: We may disclose your PHI to health oversight agencies for activities authorized by law, such as audits, investigations, inspections, and licensure.
g. Judicial and Administrative Proceedings: We may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process.
h. Law Enforcement: We may disclose your PHI for law enforcement purposes, such as to report certain types of wounds or injuries, or to comply with a court order, warrant, or other legal process.
i. Research: We may use and disclose your PHI for research purposes when the research has been approved by an institutional review board and privacy protections are in place.
j. Organ and Tissue Donation: If you are an organ donor, we may disclose your PHI to organizations that handle organ procurement, transplantation, or donation.
k. Workers' Compensation: We may disclose your PHI for workers' compensation or similar programs that provide benefits for work-related injuries or illnesses.
l. Military and Veterans: If you are a member of the armed forces, we may disclose your PHI as required by military authorities.m. Inmates: If you are an inmate, we may disclose your PHI to the correctional institution or law enforcement official having custody of you.
Your Rights Regarding PHI
You have the following rights with respect to your PHI:
a. Right to Inspect and Copy: You have the right to inspect and copy your PHI that we maintain, with certain exceptions. To request access, submit a written request to our Privacy Officer. We may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request.
b. Right to Amend: You have the right to request an amendment to your PHI if you believe it is incorrect or incomplete. To request an amendment, submit a written request to our Privacy Officer, specifying the information you believe is incorrect and why. We may deny your request if we believe the information is accurate and complete, or if we did not create the information.
c. Right to an Accounting of Disclosures: You have the right to request an accounting of disclosures of your PHI made by us in the past six years, except for disclosures made for treatment, payment, or healthcare operations, and certain other disclosures. To request an accounting, submit a written request to our Privacy Officer.
d. Right to Request Restrictions: You have the right to request a restriction on our use or disclosure of your PHI for treatment, payment, or healthcare operations. We are not required to agree to your request but will consider it. To request a restriction, submit a written request to our Privacy Officer, specifying the restriction you are requesting and to whom it applies.
e. Right to Request Confidential Communications: You have the right to request that we communicate with you about your PHI in a certain way or at a certain location. To request confidential communications, submit a written request to our Privacy Officer, specifying how or where you wish to be contacted.
f. Right to a Paper Copy of This Notice: You have the right to receive a paper copy of this Notice, even if you have agreed to receive it electronically. To obtain a paper copy of this Notice, contact our Privacy Officer.
g. Right to be Notified of a Breach: You have the right to be notified in the event that we discover a breach of your PHI.
Transmission of PHI
We are committed to protecting the privacy of your PHI and will ensure that any electronic transmission of PHI complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 CFR 164). This includes the use of Secure-Socket Layer (SSL) or equivalent technology for the transmission of PHI, as well as adherence to all applicable security standards for online transmissions of PHI.
Changes to This Notice
We reserve the right to change this Notice and the revised Notice will be effective for PHI we already have about you, as well as any information we receive in the future. We will post a copy of the current Notice in our office and on our website. The Notice will contain the effective date on the first page.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the Secretary of the Department of Health and Human Services. You will not be retaliated against for filing a complaint.Contact Information
To exercise any of your rights, or if you have any questions about this Notice or our privacy practices, please contact our Privacy Officer Lydia Smith at:
Nurojoy, 2810 N Church St, PMB 48521, Wilmington, Delaware 19802
support@nurojoy.com
This Notice is provided in accordance with the Notice of Privacy Practices for Protected Health Information from the Department of Health and Human Services' Model and is applicable across all US states. Rights of Specific Jurisdictions within the US Certain states may have additional privacy protections that apply to your PHI. The following is an example of specific rights in the state of California. If you reside in a state with additional privacy protections, you may have additional rights related to your PHI.
California Residents:
a. Right to Access: In addition to the rights described above, California residents have the right to request access to their PHI in a readily usable electronic format, as well as any additional information required by California law. To request access, submit a written request to our Privacy Officer.
b. Right to Restrict Certain Disclosures: California residents have the right to request restrictions on certain disclosures of their PHI to health plans if they paid out-of-pocket for a specific healthcare item or service in full. To request such a restriction, submit a written request to our Privacy Officer.
c. Confidentiality of Medical Information Act (CMIA): California residents are protected by the Confidentiality of Medical Information Act (CMIA), which provides additional privacy protections for medical information. We are required to comply with CMIA in addition to HIPAA.d. Marketing and Sale of PHI: California residents have the right to request that their PHI not be used for marketing purposes or sold to third parties without their authorization. To request a restriction on the use of your PHI for marketing or the sale of your PHI, submit a written request to our Privacy Officer.e. Minor's Rights: If you are a minor (under the age of 18), you have the right to request that certain information related to certain sensitive services, such as reproductive health, mental health, or substance use disorder treatment, not be disclosed to your parent or guardian without your consent. To request a restriction on the disclosure of such information, submit a written request to our Privacy Officer.If you reside in a state other than California, please consult your state's specific privacy laws for information about any additional rights you may have regarding your PHI. You may also contact our Privacy Officer for more information about your rights under specific state laws.
Nurojoy Privacy Policy: Notice of Privacy Practices for Protected Health Information (PHI) - State-Specific Provisions
In addition to the privacy practices described in our Notice of Privacy Practices for Protected Health Information, we comply with applicable state-specific privacy laws related to PHI.The following are examples of a few states with additional privacy protections:
New York:
For residents of New York, we comply with the New York State Confidentiality of Information Law, which provides additional privacy protections for HIV-related information, mental health records, and genetic testing results. We will obtain written consent before disclosing such information, even for treatment, payment, or healthcare operations.
Texas:
For residents of Texas, we comply with the Texas Medical Privacy Act, which offers privacy protections beyond HIPAA, including requiring consent for certain disclosures of PHI, additional safeguards for electronic PHI, and specific requirements for the destruction of PHI. We also adhere to Texas's specific privacy protections for mental health records and substance use treatment records.
Florida:
For residents of Florida, we comply with Florida's privacy laws, which offer additional protections for mental health records, HIV/AIDS-related information, and substance abuse treatment records. We will obtain written consent before disclosing such information, even for treatment, payment, or healthcare operations. We also implement specific security measures to protect electronic PHI, as required by Florida law.
Illinois:
For residents of Illinois, we comply with Illinois's specific privacy laws related to mental health records, HIV/AIDS-related information, and genetic testing results. We will obtain written consent before disclosing such information, even for treatment, payment, or healthcare operations. In addition, we will notify patients of any unauthorized access to their electronic PHI, as required by Illinois law.
Massachusetts:
For residents of Massachusetts, we comply with Massachusetts's specific privacy laws related to mental health records, HIV/AIDS-related information, and genetic testing results. We will obtain written consent before disclosing such information, even for treatment, payment, or healthcare operations. We also implement specific security measures to protect electronic PHI, as required by Massachusetts law.
California:
For residents of California, we comply with the Confidentiality of Medical Information Act (CMIA), as well as California's specific privacy laws related to marketing, sale of PHI, and minors' rights. We will obtain written consent before disclosing certain information and adhere to additional privacy protections, as required by California law.
Call/Email/Text Messaging Consent: You expressly consent to allow Beluga or its healthcare practitioners to call, email, or text you (via SMS and/or MMS) with or regarding Personal Data (as defined in the Beluga Privacy Policy), appointments, or similar matters related to your telemedicine encounters using the contact information you have provided. Any calls or texts to you may be placed using an auto-dialer or a pre-recorded or artificial voice, even if your number is on a do-not-call list. Your phone carrier’s normal rates may apply. This is consent, not a condition of purchase. You may revoke this consent at any time by emailing us at admin@belugahealth.com.
This Asynchronous Telemedicine Informed Consent is valid during your entire treatment with Beluga.
