36800 Sidewinder Rd. Ste A-4, Carefree, AZ 85377
EC Agreement
CAREFREE INTERNAL MEDICINE ELECTRONIC COMMUNICATIONS AGREEMENT
Carefree Internal Medicine, PC, an Arizona professional corporation (“we”, “us” or “Practice”) and the undersigned patient (“you” or “Patient”) enter into this Electronic Communications Agreement (“EC Agreement”) regarding the use of e-communications/transmissions, such as e- mail, mobile or cellular telephone (if applicable), Skype, FaceTime, internet portal-enabled communications, or any other version of electronic communication (collectively “E- Communication”) with respect to Patient protected health information (“PHI”). (Practice and Patient are each individually called “Party” or collectively as “Parties”).
PATIENT AUTHORIZATION DESPITE RISKS OF PRIVACY BREACH
While Practice and Patient commonly rely on electronic communication platforms and services to achieve immediate communication, there are risks that you acknowledge that are outside the Practice’s control. You authorize all forms of E-Communications exchanged between Parties unless you instruct us otherwise in writing. You acknowledge that the use of E-Communication is inherently risky and prone to unintentional release of data. E-Communications may incorporate or communicate references to your PHI with sensitive health and personal identification information included. You acknowledge that E-Communications lack any absolute guarantee of privacy and are subject to: system privacy failure, cookies and other tracking efforts, phishing attacks, hacking attacks, data breaches, unintended misdirections, misidentifications of senders/ recipients, technology failures, and user errors.
You agree to undertake efforts to protect your privacy, which include refraining from including sensitive information in E-Communications that you do not want to be at risk of any data security breach. Practice will undertake reasonable efforts to protect your privacy to the extent required by applicable laws. You authorize us to respond electronically to all E-Communications that appear to be provided by you, whether or not such communications arrive from the electronic contact information that you provide us.
PATIENT MUST PROVIDE ACCURATE AND UPDATED CONTACT INFORMATION
You agree to provide us with your accurate electronic contact information (email address, Skype or FaceTime contact information, and any other applicable E-Communication contact information). You will immediately inform us of any changes or corrections to your electronic contact information as an effort to avoid misdirected E-Communications. You will also inform us of your permanent mailing residential address, and any changes to that address.
PATIENT MUST NOT RELY ON ELECTRONIC COMMUNICATION IN EMERGENCIES: USE 911 AND GET TO THE EMERGENCY ROOM
Practice does not guarantee that we will read your E-Communications immediately or within any specific amount of time. You agree not to utilize E-Communications to contact us regarding an emergency or time- sensitive situation, as there is too much risk that the communication response may be delayed, ineffective, untimely, or inadequate. You MUST call 9-1-1 in an emergency, immediately seek emergency medical attention, or both.
HIPAA/HITECH/DATA PRIVACY LAWS
Practice values and appreciates your privacy and will take commercially reasonable steps to protect Patient’s privacy in compliance with the Health Insurance Portability and Accountability Act of 1996 and related laws such as HITECH (collectively referred to as “HIPAA”). Practice shall also comply with other data privacy laws related to Patient’s data.
We will obtain your express written or electronic consent (to the extent required by applicable law) if we are required or requested to forward your identifiable PHI to any third party other than as authorized in our Notice of Privacy Practices or as authorized or mandated by applicable law. You hereby consent to the use of E- Communication of Patient's information as we consider it helpful to coordinate care and schedule mobile visits with you and all those responsible for providing or overseeing your care. You agree to identify individuals or entities authorized to receive your PHI from us in connection with authorized consulting, education, and all other aspects of your care, and we may share your PHI with such parties without additional written or electronic consent from you.
You have the right to ask us for a copy of your PHI, including an explanation or summary. The following services will not be the subject of any additional charges to you (and are outside Services Fees): maintaining PHI storage systems; recouping capital or expenses for PHI data access, PHI storage, and infrastructure; or retrieval of PHI electronic information.
Practice may charge you fees for actual costs that we incur to provide such electronic PHI, but only to the extent authorized by applicable laws. Such fees may include, to the extent lawful: skilled technical staff time spent to create and copy PHI; compiling, extracting, scanning, and burning PHI to media and distributing the media (with media costs charged to you); and time spent by our administrative staff preparing additional explanations or summaries of PHI. If you request PHI on a paper copy, or portable media (such as compact disc/CD, universal serial bus/USB flash drive), we may charge you for our actual supply costs for such equipment, and you agree to pay us any such costs.
PATIENT ACCEPTS RESPONSIBILITY FOR ELECTRONIC COMMUNICATION RISKS
You will hold Practice (and our owners, officers, directors, agents, and employees) harmless from and against any and all demands, claims, and damages to persons or property, losses, and liabilities, including reasonable attorney fees arising out of or caused by E-Communication (whether encrypted or not) losses or disclosures caused by any of the risks outlined above, by some person or entity other than Practice, or not directly caused by us. Patient acknowledges and understands that, at our discretion, E-Communication may or may not become part of your permanent medical record. These terms do not relieve Practice from Practice's obligations to comply with all applicable E-Communication laws.
You acknowledge that your failure to comply with the terms of this EC Agreement may result in our terminating the use of E-Communication methods with you and may cause the termination of your Agreement for our services.
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
We are required to provide you a copy of our Notice of Privacy Practices, which states how we may disclose your health information. You hereby acknowledge receipt of the Notice of Privacy Practices.
CONSENT TO DISCLOSURE OF BILLING INFORMATION
By signing this EC Agreement, you consent to Practice disclosing all information relevant to billing, insurance, and reimbursement regarding any and all substance abuse disorders that you might have, for the purpose of obtaining reimbursement from private or public insurers.
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov. For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
ADDITIONAL TERMS
This EC Agreement will remain in effect until either Party provides written notice to the other Party revoking this EC Agreement or otherwise revoking consent to E-Communications between the Parties. Such revocation will occur thirty (30) calendar days after written notice of such revocation.
Revocation of this EC Agreement will preclude us from providing treatment information in an
electronic format other than as authorized or mandated by applicable law or by you. Either Party
may use a copy of this signed original EC Agreement for all present and future purposes.
Parties agree to take such action as is reasonably necessary to amend this EC Agreement from time to time as it is necessary for the Parties to comply with the requirements of the Privacy Rule, the Security Rule, and other provisions of HIPAA, or other applicable law. Parties further agree that this EC Agreement cannot be changed, modified or discharged except by an agreement in writing and signed by both Parties.
If any term of this EC Agreement is deemed invalid or in violation of any applicable law or
public policy, the remaining terms of this EC Agreement shall remain in full force and effect, and
this EC Agreement shall be deemed amended to conform to any applicable law.
Each participating Patient (and authorized representative when applicable) must sign this EC
Agreement. Your signature represents that you understand and agree to the terms and conditions described within this EC Agreement.