InTeleDerm is registered to do business as InTeleDerm. By utilizing InTeleDerm you acknowledge the following: (1) your acknowledgement that you have either received or that you were provided a reasonable opportunity to electronically review the notice of InTeleDerm’s notice of privacy practices (“Notice of Privacy Practices) and (2) your consent for InTeleDerm’s and its designees’ use and disclosure of your protected health information (“PHI”) for treatment, payment or healthcare operations as defined by the Health Insurance Privacy and Accountability Act of 1996 (the "HIPAA Privacy Rule") in connection with the telehealth dermatology services (referred to as the “InTeleDerm® Service” or “InTeleDerm Service”) which are provided to you by InTeleDerm
(“InTeleDerm”). The InTeleDerm Service comprises a network of participating dermatologists (“Participants) which delivers dermatology services on a telehealth basis through the website located at http://www.InTeleDerm.com (“Website”).
By submitting your information to the InTeleDerm Service, using the Website in order to request telehealth dermatology services, your PHI will be made available online through the InTeleDerm Service. Participants will have access to your PHI by using the InTeleDerm Service to review your request for telehealth dermatology services. InTeleDerm will have access to your PHI as the Administration of the InTeleDerm Service. InTeleDerm’s designated payment processor will have access to your PHI for use in connection with payment related activities. Other third parties may have access to your PHI either to fulfill healthcare operations of the Participants or as a result of a valid authorization which you have granted.
Please read the following information carefully:
1. I understand and consent to the use and/or disclosure of my PHI by InTeleDerm and its designees for the purposes of treatment, payment, and healthcare operations related activities which are permitted by the HIPAA Privacy Rule.
a. As a result of your submitting your PHI to the InTeleDerm Service to request delivery of online teledermatology Participants will have the ability to access your PHI for the provision of teledermatology medical services using theInTeleDerm Service. Your PHI will be disclosed and used by the Participant who has elected to fulfill your request for such services. Your PHI will be accessed, stored, and maintained online by InTeleDerm and its designees.
b. When you pay for dermatology services which are delivered through the InTeleDerm Service, your PHI will be used or disclosed by the third party payment processor in connection with the processing of your payment information. In addition, your PHI may be disclosed to or used by a Participant in connection with payment related activities. InTeleDerm and its designees may use your PHI for other payment or reimbursement activities for the provision of services.
c. Participants and business associates (e.g., entities which perform functions such as e-prescribing, data center hosting, managed security services, and ongoing software development and support) may use or disclose your PHI in connection with healthcare operations related activities such as communications about your treatment, case management, care coordination, direct or alternative treatments, therapies, health care providers, or settings of care, and communications pursuant to a valid authorization by you.
2. I am aware that InTeleDerm maintains a Notice of Privacy Practices which explains the types of uses and disclosures that InTeleDerm and its designees that are permitted or required to make under the HIPAA Privacy Rule. By signing this Consent, I acknowledge that I have received a copy of the Notice of Privacy Practices.
3. I understand and acknowledge that, in its Notice of Privacy Practices, InTeleDerm has reserved the right to change its Notice of Privacy Practices as permitted or required by the HIPAA Privacy Rule. I understand that I may obtain a copy of the Notice of Privacy Practices at any time by sending a written request to the following address: InTeleDerm, Attn: Privacy Officer, 21346 Brewers Farm Lane Carrollton, VA 23314. I understand and acknowledge that I have the right to request restrictions on how my PHI is used or disclosed to carry out treatment, payment or healthcare operations or to restrict uses and disclosures to those who are involved in my care or payment of my care.
5. I understand and acknowledge that InTeleDerm is generally not required to agree to restrictions requested by me regarding my PHI. However, InTeleDerm reserves the right to not provide care if such restrictions are requested by me; in such a case, I understand that I will not be eligible to use the InTeleDerm Service if InTeleDerm exercises that right.
6. I understand and acknowledge the risks of electronic communications (e.g., via the InTeleDerm Service, text messages, and email) in that they are not secure and I consent to receiving such communications. If any PHI is communicated, then only the minimum necessary amount of PHI will be used.