PATIENT AGREEMENT

TERMS AND CONDITIONS OF SERVICE

 

CONSENT TO TREAT

 

It is the policy of Haig M.D. Mobile Medicine that every patient has the right to the information necessary to be able to understand and participate in treatment decisions that reflect the patient's wishes to the maximum extent possible. It is the objective of this policy to assure the patient's right to give Informed Consent is understood. “Informed Consent” is a knowing, voluntary grant of permission to permit medical treatment.

 

You acknowledge and agree that you have requested to receive medical treatment and services from Haig M.D. Mobile Medicine (the “Practice”).  Further, you authorize and provide Informed Consent to the rendering of medical treatment and services, including medical diagnostic procedures and medical care, by your treating provider as considered necessary and appropriate based on the treating provider’s professional judgment.

 

You have the right to decline treatment and services at any time, but you may be responsible for paying for services already rendered. You also acknowledge that no assurances or guarantees have been made to you by the Practice or any of the Practice’s staff concerning the outcome and/or results of any medical treatment or services.

 

You consent to receiving a medical screening by Haig M.D. Mobile Medicine, which may occur through in-person visits and/or telehealth services, and understand that there are certain risks associated with receiving care. You understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risk of injury or even death. You hereby acknowledge that the Practice will consult with you about the risks and benefits associated with receiving treatment and care via in-person visits and/or telehealth services upon your request. The Practice will further provide patient with material information regarding the proposed care, treatment, services, medication, interventions, or procedures, including anticipated risks, benefits, side effects, and alternatives to the proposed treatment, as well as the risks of non-treatment; and ascertain that the patient understands the discussion and agrees to the treatment.

 

You acknowledge that you have made the medical staff aware of all your known health conditions, allergies and medications you are taking, including herbal medications/supplements.

 

You further understand that you are assuming the risk of exposure to the coronavirus (or other public health risk) by having these services provided. Moreover, by inviting the Practice into your home, you understand that there may be an increase in risk to exposure to your family members and other individuals who live or come to your home. You agree to inform the Practice if either yourself or anyone you live with or anyone you have been in contact with displays any symptoms consistent with the coronavirus.

 

DISCLAIMER: The main treating provider of medical services is not yet a board certified medical doctor. Accordingly, you acknowledge, agree and consent to receiving treatment by a licensed medical professional (the treating provider), who is licensed to practice medicine, but may currently be under training.

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THE TERMS OF SERVICE

These Terms of Service (“Terms”) constitute a contract that explains the legally binding terms of your use of the Practice’s Service. The Terms not only govern your use of the medical services provided by Haig M.D. Mobile Medicine, but also your access to and use of the site and its related internet-based services, features, content, and functionality, including the scheduling/booking service (the “Service”). By using Haig M.D. Mobile Medicine’s Service, you accept and agree to be bound by these Terms and any conditions or notices contained or referenced within.

 

You acknowledge that these Terms may be modified by us at any time, in our sole discretion, and that any modifications will be effective upon the electronic posting on the site.  Your continued use of the Service shall indicate your acceptance of any modified terms. Further, you agree that we may at any time, in our sole discretion, with or without prior notice to you, modify, cancel, update, reconfigure, supplement, limit, terminate, or otherwise alter the Service or any part thereof, whether temporarily or permanently.

 

By using the Service, you also agree that we may send you various communications by email or by posting them on the site.  You agree to notify us promptly if your email address changes.  This consent covers all actions you conduct through our Service. Should you decide that you do not wish to receive communications by email, please contact us at mobilemedicine@haigmd.com. Your withdrawal of consent will be effective within a reasonable time after we receive such notice.  A withdrawal of consent will not affect the enforceability of these Terms.

 

In-Person Visits: The Practice provides mobile, in-person visits at patient-specified locations for both adult and pediatric patients. Available services for in-person visits include scheduled, primary-care services as well as well as short-noticed, non-emergency, sick-care services to treat illnesses or minor injuries. For example, during an in-person visit your treating provider may perform wellness exams, physicals, assess and treat chronic conditions, assess and treat illness like the common cold, flu, stomach aches or ear infections, or assess and treat minor injuries. Please note, the Practice does not provide general obstetrics services or any emergency services.

 

Telehealth Services: The Practice also provides non-emergent, telehealth and remote patient monitoring services, whereby patients may receive limited healthcare services without in-person contact between the patient and provider. Telehealth services and remote monitoring services are available only in limited circumstances, and only at the Practice’s sole discretion. Telehealth services are not intended to replace the need for in-person medical treatment and evaluation. By agreeing to the terms and conditions of our Patient Agreement, you are also agreeing to the use of telehealth services. However, at any time you may opt not to receive telehealth services.

 

Under certain limited circumstances, your treating provider (and/or the Practice) may determine, in his or her best judgment, that he or she is unable to provide medical treatment and services to you, based on information received or conduct occurring during the course of a visit. However, in no case will the Practice or any of its staff make such a determination based on any patient’s sex, sexual orientation, gender-identity, race, creed, color, religion, national origin or disability, or status in any other protected class.

THE PRACTICE DOES NOT PROVIDE EMERGENCY MEDICAL CARE AND IS NOT A REPLACEMENT FOR PRIMARY CARE DOCTOR OR SPECIALIST:

If you have an emergency, such as chest pain, severe shortness of breath, severe headache or bleeding, call 911 or proceed directly to the nearest hospital emergency room.

 

You understand and acknowledge that the Practice is not a replacement to a primary care doctor or specialist. You understand and acknowledge that it is your responsibility to follow up on the recommendations the treating provider makes during the in-person visit or telehealth service provided. You understand and acknowledge that if the treating provider discovers a pathology that requires emergent care, you will be advised to go to the emergency department and it is your responsibility to follow the recommendations of the treating provider. If you refuse to comply with the treating provider’s recommendations, your actions will constitute self-harm, against the advice of the treating provider, and you will be liable for your own actions, or lack thereof, and any derivative medical consequences, injuries or death.

 

You understand and acknowledge that going to an outpatient clinic or emergency department/urgent care may provide superior care given their more comprehensive therapeutic and diagnostic capabilities. Accordingly, you understand and acknowledge that the Practice does NOT provide certain types of diagnostic imaging, including but not limited to X-ray imaging, MRI scans, MRA scans, CT scans, mammography and the like. Similarly, the Practice will not perform comprehensive ultrasound imaging; however, the Practice may perform preliminary reading of findings based on the use of basic and portable ultrasound imaging devices. 

PRESCRIPTION POLICY:

You understand and acknowledge that no assurances or guarantees will be made by the Practice or any of the Practice’s staff concerning the prescription of any medication(s) and/or dispensed medication(s). Your treating provider, based on his or her professional judgment, is solely responsible for determining the clinical appropriateness and necessity, or lack thereof, for any prescribed medication(s). At the time of prescribing any medication(s), your treating provider will advise you on known risks and potential benefits of the medication(s).

 

You further understand that Scheduled II, III, or IV drugs, or any other drug that is reasonably determined by the prescribing provider and/or the Practice to pose a risk of abuse or diversion, will only be prescribed, not dispensed, to patients only when the prescribing provider determines such medications to be medically appropriate after a complete in-person evaluation to assess the condition for which the medications are indicated. The Practice never requires or guarantees that any Scheduled II, III, or IV drugs will be prescribed or continued.

PEDIATRIC VACCINATION POLICY:

The Practice follows the vaccination schedules put out by the American Academy of Pediatrics (AAP) and Centers for Disease Control (CDC). The Practice is committed to helping families understand that vaccinations are both safe and effective. 

 

For children who are not adequately vaccinated at the time of the patient’s first appointment with the Practice, the Practice reserves the right to refuse treatment of the pediatric patient. The Practice may choose to treat the pediatric patient, but highly recommends the pediatric patient’s commitment to a formal vaccination plan to bring the child’s immunization into compliance with the AAP schedules. 

SUBSEQUENT CARE & COORDINATION WITH YOUR PRIMARY CARE PROVIDER:

It is your sole responsibility to follow through with your primary care provider on any medical conditions or potential abnormalities detected or not detected by the visit, and to obtain a medical examination by your primary care provider related to the findings, or lack of findings, of this visit.

EQUITABLE ACCESS & NON-DISCRIMINATORY CARE POLICY:

Understand that the Practice does not have any medical office open to the public or any other public facility where the Practice provides medical services.  You understand and agree that the Practice’s mobile care model means that the Practice has no control over any physical accommodations at the specific locations where you may request and/or receive medical services. Regardless, it is the Practice’s policy to make all commercially reasonable efforts to provide accommodations that will allow seniors and people with disabilities to request and receive equitable access and non-discriminatory medical care. As such, to the extent practicable, applicable, and/or required by law, and other applicable California state laws and regulations that prohibit discrimination on the basis of disability.

PAYMENT FOR SERVICES / FINANCIAL AGREEMENT AND GUARANTEE:

The Practice generally charges flat fee for different types of the services it provides (the “Service Fee”).  Service Fees are your financial responsibility and must be made by credit card or cash. If timely payment is not made, the Practice may engage third parties to collect any outstanding payments. 

 

Accordingly, the Practice does not accept Medicare approved amounts, Medicaid or Medi-Cal, and/or insurance coverage as a form of Service Fee payment. You are responsible for any applicable Service Fee payments, and your credit card will be charged accordingly.

 

The balance of your claim is your financial responsibility, whether or not your health insurance plan pays your claim.

 

You accept full and complete financial responsibility for all medical services rendered to you and agree to pay for the services in full prior to the commencement of services. You further acknowledge, understand and agree that in the event that you fail to make such payments in accordance with the payment policies of the Practice, or in the event of default of your financial obligation to pay for services rendered, the Practice may terminate the “doctor-patient” relationship with you. Furthermore, in the event of your default of your financial obligation, should your account be turned over to an external collection agency for non-payment, you agree to pay any associated collection costs.

 

THE PRACTICE DOES NOT PARTICIPATE IN MEDICARE. THE PRACTICE DOES NOT PARTICIPATE IN MEDICAID. THE PRACTICE IS NOT A MEMBER OF AN INSURANCE PLAN. MOREOVER, BY SIGNING BELOW AND/OR CHECKING THE TERMS AGREEEMNET BOX ONLINE, YOU ACKNOWLEDGE THAT THE PRACTICE DOES NOT ACCEPT MEDICARE, MEDICAID, MEDI-CAL AND/OR OTHER INSRUANCE COVERAGE AS A FORM OF PAYMENT AND THAT YOU ARE INDEPENDENTLY RESPONSIBLE FOR SERVICE FEE PAYMENTS.

 

You acknowledge that you have read and understood all the information contained in this Patient Agreement. You understand that the terms herein are contractual and not a mere recital; and that you agree to these Terms at your own free act and void of any coercion.  The permissions granted herein shall begin on the date you book your appointment and shall remain effective until terminated. 

RETENTION OF RECORDS:

The Practice shall retain health care records for at least six (6) years after their receipt or production, unless a longer period is required by law (e.g., for records of minors). The Practice may destroy health records once it is no longer required to retain them.

COORDINATION WITH HEALTH RECORDS AND HEALTH DATA:

In an effort to gain a more complete picture of your health and help avoid unnecessary testing and duplicated efforts, the Practice supports coordinating access to your health records and health data that may be created by various third-party sources before, after and/or in between your visit(s). This may include access to (1) your patient health records from other providers and/or (2) your electronic health data created by your use of different wellness, fitness or medical devices.

 

AUTHORIZED REPRESENTATIVE:

In exchange for and in connection with any and all of the service(s) provided to you by the Practice, by signing this agreement you hereby designate the Practice as your duly authorized representative in connection with all matters arising from or relating to the services provided, and you agree to cooperate with and take all steps necessary to effectuate, perfect, confirm or validate the authorization of the Practice as your authorized representative, as addressed herein.

INDEMNIFICATION:

You acknowledge that you shall be liable for, and shall indemnify, defend and hold harmless the Practice/Haig M.D. Mobile Medicine, its parent, subsidiaries and affiliates and its shareholders, officers, directors, employees, agents and advisors, from and against any and all liability, loss, claim, lawsuit, injury, cost, damage, causes of action, proceedings, judgments, awards, executions and liens, or expense whatsoever, including reasonable attorneys’ fees and court costs (whether brought by third party or otherwise) (collectively, the “Claims”) due to or arising out of, incident to or in any manner occasioned by (1) the performance or nonperformance of any duty or responsibility by patient, (2) any tortious acts committed by you or any other person at your residence or other location of the visit, (3) any damages resulting from any defects at your residence or location, (4) your placement or transmission of any message, any content, or other information or materials through the Service, or (5) your breach or violation of the law or of these Terms, but only to the extent, and only in such amount, that such liability, loss, claim, lawsuit, injury, cost, damage or expense is not covered and paid by third party insurance.

 

The foregoing indemnification provision shall in all instances be deemed to be subordinate to any third-party insurance coverage that may cover all or any portion of any indemnification claim, including without limitation the patient’s homeowner’s insurance policy, as applicable.

DISCLOSURE OF PROVIDER INFORMATION & PATIENT GRIEVANCES:

All the Practice’s clinicians are licensed, certified or otherwise permitted to provide medical services in the state of where medical services are provided.  Your treating provider’s information, including name, highest level of academic degree, specialty, license status, and license number, and board certification (where applicable) are available on our website www.haigmd.com.

 

Should you have any questions, comments, feedback or grievances, you may always reach out directly to the Practice at mobilemedicine@haigmd.com

 

Additionally, patients always have the right to report concerns or grievances to the appropriate state medical board, or other applicable regulatory body.

NOTICE OF PRIVACY POLICY ACKNOWLEDGEMENT:

THE NOTICE OF PRIVACY POLICY DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY, AS IT EXPLAINS:

 

How the Practice will use and disclose your protected health information, your privacy rights with regard to your protected health information, and the Practice’s obligations concerning the use and disclosure of your protected health information.

 

You acknowledge that you have received a copy of the Practice’s HIPAA Notice of Privacy and have been provided an opportunity to review it.  You further acknowledge that the Practice’s Notice of Privacy Policy is available from the Practice upon request, and has been made available to you on the website.

CONSENT TO EMAIL AND ELECTRONIC COMMUNICATIONS:

You consent to the use of unsecured email, mobile phone text message, or other electronic methods of communication (“E-communications”) between yourself and the Practice, your treating provider, and any other agents or representatives of the Practice, for purposes of discussing personal material relevant to your treatment or health records. You understand that E-communications are typically not confidential means of communication and that there is a reasonable chance that a third-party (including people in your home or other environments who can access your phone, computer, or other devices; your employer, if using your work email; and/or third parties on the Internet such as server administrators and others who monitor Internet traffic) may be able to intercept and see these messages.  You have been informed of the risks—including but not limited to the risk with respect to the confidentiality of your treatment—of transmitting your protected health information by an unsecured means.  You acknowledge that E-communications are not to be used in the case of an emergency, and that you should call 911 or proceed directly to the nearest emergency room.

CONSENT TO USE OF TELEHEALTH:

You acknowledge that you have read, understand and agree to the information below, which applies if you have requested telehealth services, and that your name and identity have been correctly identified in communications with the Practice.

 

I hereby consent to receiving treatment through telehealth from the Practice as part of my health evaluation and treatment. I further give the Practice and its providers permission to consult with relevant specialists as needed during the course of my treatment, and I further consent to the Practice and its providers forwarding my medical information to my primary care provider/provider of record as needed or, upon my request, to any other provider. I am providing the foregoing consents based on my understanding of the following:

 

1. During my treatment through telehealth, my provider and I will be in different physical locations and my medical and/or health information will be communicated to health care providers at those other physical locations. I may benefit from the use of telehealth, including from the increased availability and access to care, but results cannot be guaranteed or assured.  Furthermore, the use of telehealth may present certain risks, such as delays in medical evaluation and treatment due to technological issues, the need to reschedule if the transmitted information is of insufficient quality, or potential failure of security protocols which could cause disclosure of personal information.  

2. In addition, I understand a lack of access to my complete medical record could result in adverse or other unintended results, and I understand it is my responsibility to share complete and accurate information with my provider.

3. My treating provider’s information, including name, highest level of academic degree, specialty, license status, license number, board certification (where applicable), are available through Haigmd.com website.

4. In the event of an adverse reaction to treatment or the inability to communicate as a result of a technological failure, I understand that I may contact my treating provider for further assistance or to schedule follow-up care by calling 747-7DR-HAIG, emailing mobilemedicine@haigmd.com or visit haigmd.com.

5. The Practice may use telehealth to conduct examinations, diagnose and treat medical conditions, interact with me in connection with prescriptions and refills, and otherwise communicate with me about my health.  I understand and agree that my provider has the sole responsibility and discretion to determine whether telehealth is appropriate for the diagnosis or treatment of my specific condition(s).

6. I have the right to withdraw my consent to the Practice’s use of telehealth at any time without affecting my right to future care or treatment or risking the loss or withdrawal of the remaining benefits that are a part of the Service Fee.  Receiving treatment through telehealth does not mean that I cannot receive in-person health care services now or in the future.

7. The information and data disclosed by me during the course of my treatment through telehealth may be integrated into my medical record and will generally be protected and confidential. The Practice uses industry leading security standards to maintain the highest level of security for its patients. However, I understand and accept that, as is the case with all electronic data, there is a risk that data security protocols could fail or be breached, which may result in the unintended disclosure of my information.

8. The Practice will not provide my personally-identifiable information to any third parties without my express consent.  Notwithstanding the foregoing, I understand that my healthcare information may be shared with other individuals and entities for the Practice’s scheduling, billing, and other treatment, payment, and health care operations purposes, or other uses or disclosures permitted or required by law, and I consent to such use and disclosure solely to the extent such use or disclosure complies with applicable federal and state privacy laws.

9. The Practice and its providers are not responsible for any information lost as a result of any technical failures encountered during the course of my telehealth treatment.

10. An in-person evaluation is required prior to prescribing any schedule II, III, or IV drugs and at least every 90 days for ongoing prescriptions.  However, your doctor/treating provider – at their discretion – may choose to renew or adjust prescriptions for controlled medications via telehealth as long as you have had an in person visit in the prior 90 days.

11. I understand that if I am experiencing a medical emergency, I will be directed to call 911, and that the Practice is not able to connect me directly to local emergency services.

12. I have discussed the foregoing information with my provider and all of my questions have been answered to my satisfaction.

 

OTHER TERMS:

 

Assignment: You may not assign or otherwise transfer any rights, or delegate or otherwise transfer any of your obligations or performance, under these Terms, in each case whether voluntary, involuntary, by operation of law, or otherwise, without our prior written consent.  Any purported assignment, delegation, or transfer in violation of this section is void.  Haig M.D. may freely assign or otherwise transfer all or any of its rights, or delegate or otherwise transfer all or any of its obligations or performance, under this Agreement without your consent.  This Agreement is binding upon and inures to the benefit of the parties hereto and their respective permitted successors and assigns.

 

Entire Agreement:  These Terms constitute the complete and entire agreement between you and Haig M.D. concerning its subject matter and supersedes all prior agreements and representations between the parties.

 

Interpretation:  The use of the terms “includes,” “including,” “such as,” and similar terms, will be deemed not to limit what else may be included.  The headings in these Terms are for reference only and do not affect the interpretation of these Terms.

 

No Waiver:  A party’s failure to delay or enforce a provision under these Terms is not a waiver of its right to do so later.

 

Severability:  If any provision of this Agreement is held to be unenforceable for any reason, such provision will be reformed to the extent necessary to make it enforceable to the maximum extent permissible so as to effect the intent of the parties, and the remainder of this Agreement will continue in full force and effect.

 

Governing Law and Jurisdiction: This Agreement is governed by and construed under the laws of the State of California without reference to its conflict of law principles.  In the event of any conflicts between foreign law, rules, and regulations, and California law, rules, and regulations; California law, rules, and regulations will prevail and govern.  Each party agrees to submit to the exclusive and personal jurisdiction of the courts located in California.  All parties to these terms and conditions waive their respective rights to a trial by jury.

 

ARBITRATION:

 

In consideration of the mutual benefits and obligations set forth in this Patient Agreement, the parties, the patient and the Practice/treating provider, agree as follows:

 

Matters To Be Submitted to Arbitration: Any controversy between patient and the treating provider and/or the Practice concerning medical care shall be submitted to final and binding arbitration in accordance with the procedure set forth below. It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this Patient Agreement were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by the law of California, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this agreement understand that by entering into it they are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting use of arbitration.

 

Procedure: Any dispute or controversy between patient and doctor arising out of or in connection with the patient's medical care shall be submitted to arbitration pursuant to the following procedure:

A. If patient feels a problem has arisen in connection with medical care, patient will immediately inform doctor orally or in writing, so that doctor may have the opportunity to resolve the problem informally.

B. If the problem is not resolved informally, patient shall give doctor formal written notice of patient's claim. No such claim shall be operative if a civil action on the claim would be barred by the applicable California statute of limitations.

C. Within 30 days of receipt of the claim, doctor will arrange a meeting with patient, with or without a representative, and patient agrees to meet with doctor to attempt to resolve the problem by mutual agreement.

D. If the problem is not resolved by mutual agreement, patient will designate an arbitrator to act on patient's behalf by sending formal written notice to doctor. Within 30 days of receipt of the notice, doctor will designate an arbitrator to act on doctor's behalf. The two arbitrators so selected shall name a third arbitrator within 15 days or, in lieu of such agreement on a third neutral arbitrator by the two arbitrators so appointed.

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Effect of Agreement: Patient agrees that this arbitration agreement binds patient, his or her heirs, assigns or personal representative, and doctor, doctor's professional corporation or partnership, if any, doctor's employees, partners, heirs, assigns or personal representative. Patient also consents to the intervention or joinder in the arbitration proceeding of all parties relevant to a full and complete settlement of any controversy arbitrated under this agreement.

Interpretation of Agreement: Any controversy concerning the interpretation or application of this arbitration agreement itself shall also be submitted to arbitration in the manner provided above.

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By signing a copy of this agreement and/or by checking the terms and conditions box online, you agree to the above and represent that, before resorting to arbitration, you will in good faith give the treating provider the chance to resolve to your satisfaction such problems as may arise between you and the treating provider and/or the Practice.

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NOTICE: BY SIGNING AND AGREEING TO THIS AGREEMENT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL.

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PATIENT ACKNOWLEDGMENT

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You acknowledge that you (1) have read, understand and accept the terms of the Practice’s Patient Agreement; (2) have received a copy of the Practice’s Notice of Privacy Policy and further acknowledge that the Practice’s Notice of Privacy Policy is available from the Practice upon request; (3) consent to the use of E-communications between yourself and the Practice, the Practice’s providers, and/or other agents or representatives of the Practice, for purposes of discussing personal material relevant to your treatment or health records; (4) have read and understand the information contained in the Consent to Use of Telehealth above, and are providing the consents expressly set forth therein; and (5) have read and accept the Arbitration provision contained in the Patient Agreement.

 

If patient is unable to consent, you acknowledge that you agree to the terms and conditions of this agreement as the legally authorized representative of patient.