Informed Consent For Telehealth Services

Last Updated: July 15th, 2022 Welcome to Modern Ritual! Below you will find our Telehealth Informed Consent and Notice of Privacy Practices. MODERN RITUAL INFORMED CONSENT FOR TELEHEALTH SERVICES Modern Ritual (“Modern Ritual,” “we,” “us,” or “our”), itself, does not provide any healthcare services. Dermoscopic evaluative services (“Skin cancer Screening Services” or “Services”) are furnished by affiliated medical providers (“Affiliated Medical Providers” or “Providers”) practicing within independently owned and operated professional practices known as Modern Ritual Health P.C. (“Affiliated Medical Practices”). Modern Ritual Affiliated Medical Providers are an addition to, and not a replacement for, your local primary care provider. Responsibility for your overall medical care should remain with your local primary care provider. IF YOU ARE EXPERIENCING A MEDICAL EMERGENCY, PLEASE CALL 911 OR GO TO YOUR NEAREST EMERGENCY ROOM FOR EVALUATION AND TREATMENT. DO NOT RELY ON COMMUNICATION THROUGH THIS WEBSITE, THE PATIENT PORTAL, OR OUR SERVICES FOR URGENT MEDICAL NEEDS. WHAT IS TELEHEALTH? Telehealth is the remote delivery of healthcare services by means of interactive technologies (e.g., phone, synchronous text, asynchronous text, or video sessions) between a patient and a healthcare provider, such as a doctor or nurse practitioner, who are not in the same physical location. You do not go to a clinic or hospital and do not need to be in the same physical location as your provider. Telehealth services offered via Modern Ritual affiliated providers include at-home dermoscopic evaluative services and consultations. HOW DO I GET TELEHEALTH SKIN CANCER SCREENING SERVICES? ● Click the “Get Spot Check” button on the Modern Ritual Website. ● Pick your choice of “Spot Check” packages. ● Answer our Skin Cancer Screening quiz. ● Purchase our At-Home Skin Cancer Screening Kit. ● Take photographs of your skin using our smartphone attachment. ● Schedule your return pick-up for your Skin Cancer Screening Kit. ● Within two business days, receive recommendations from a board-certified affiliated provider. HOW DOES TELEHEALTH HELP ME? ● You will not have to travel to a clinic to receive skin cancer screenings. ● You will be virtually and asynchronously connecting with doctors who can offer advice and provide reassurance. ● You will be provided with innovative, secure, and convenient telehealth solutions. CAN TELEHEALTH BE BAD FOR ME? ● This technology has potential risks, including unauthorized access or breaches of information, loss of information, and technical difficulties, which cannot be predicted or fully controlled. ● The level of help and the quality of care you receive is directly proportional to the quality and timeliness of the health information you provide. ● You and your provider will not be in the same room, so it may feel different than an in-office visit. ● If the provider determines that your condition is not appropriate for a telehealth encounter or otherwise, your provider may decide you still need an in-office visit with your primary care doctor or other healthcare professional. ● Modern Ritual affiliated medical practices cannot make guarantees about the results of the telehealth Services. WILL MY TELEHEALTH INFORMATION BE PRIVATE? ● The health data collected digitally will be sent to your Provider in a safe and secure manner using a HIPAA-compliant platform to ensure the confidentiality and security of your healthcare information. ● Your provider will have safeguards to protect your data from being viewed by anyone else. ● All medical reports resulting from the telehealth visit are part of your medical record. ● You have the right to request a copy of your medical records which will be provided to you at a reasonable cost of preparation, shipping, and delivery. ● You are responsible for information privacy and security on your device, including your computer, tablet, or phone, in your own location. ● When you have health information displayed, it is your responsibility to ensure you are located in a private area so that other people cannot see your information. If there are other people nearby, they may see information you do not want them to know. ● If you use the Internet for telehealth, use a network that is private and secure. ● There is a very small chance that someone could use technology to hear or see your telehealth visit. ● In consenting to this agreement, you agree not to screenshot any telehealth data, unless you notify your provider and both you and your provider agree to this. ● If you or your Provider determine that your telehealth privacy or security settings are not adequate, either you or your Provider may discontinue the Services at any time. ● Your healthcare information may be shared with other individuals for operational, quality assurance, scheduling, and billing purposes. ● If you have a real-time consultation, persons may be present other than the Provider during such real-time consultation in order to operate the telehealth technologies. You will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of your medical history/examination that are personally sensitive to you; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time. WHAT IF I WANT AN IN-OFFICE SCREENING, NOT TELEHEALTH? There are alternatives to telehealth, such as in-person services. However, all skin cancer screenings by Modern Ritual’s affiliated providers are by telehealth only. You will be informed by your Provider if your health needs cannot be met via telehealth and if an in-office visit is required by another health professional. WHAT IF I TRY TELEHEALTH AND DON’T LIKE IT? ● You have the right to refuse or stop using telehealth at any time. Your refusal will be documented in your medical record. You understand that your refusal will not affect your right to future care. ● You can still get an in-office visit with your primary care doctor or other health professionals if you no longer want a telehealth skin cancer screening. ● If you decide you do not want to use telehealth or decide to revoke your refusal, please email hello@getmr.com and state that you want to stop receiving the telehealth Services or you are revoking your refusal of telehealth Services. HOW MUCH DOES A TELEHEALTH SKIN CANCER SCREENING COST? ● Modern Ritual affiliated medical practices and providers offer competitive cash-pay prices for skin cancer screenings. ● The fee for one spot check is eighty-five dollars ($85.00 USD). ● The fee for three spot checks is one hundred fifty dollars ($150.00 USD). ● The fee for an annual membership is four hundred fifty dollars ($450.00 USD). ● All fees are subject to change. CAN I USE TELEHEALTH SKIN CANCER SCREENINGS FOR EMERGENCIES? ● Modern Ritual and its affiliated providers do NOT provide emergency services and will NOT monitor your data 24/7. ● In the event of a medical emergency please call 9-1-1 immediately and follow up with your primary care doctor when stable. WHAT ELSE DO I NEED TO KNOW ABOUT TELEHEALTH SERVICES? ● There are potential risks to telehealth, including technical interruptions or difficulties, unauthorized access, data errors, or internet connection issues. ● Modern Ritual and its affiliated providers and medical practices are not responsible for technical problems over which it has no control and cannot guarantee the technology will be available or work as expected. You agree to hold harmless Modern Ritual its and affiliated providers, employees, contractors, agents, directors, members, managers, shareholders, officers, representatives, assigns, parents, predecessors, and successors for delays in evaluation or for information lost due to such technical failures. ● Modern Ritual affiliated providers offer access to at-home dermoscopic evaluative Services via telehealth. Modern Ritual affiliated providers provide recommendations and consultations but do not provide emergency medical services. In the event of a medical emergency, please call 9-1-1 immediately. ● Your healthcare provider may contact you regarding the healthcare information you provide and these communications may be monitored or recorded for quality control purposes upon your consent. ● Telehealth is not a substitute for keeping your primary healthcare provider fully informed of your medical condition and any changes in your healthcare. Please stay in touch regularly with your primary healthcare provider. Modern Ritual affiliated medical practices do not offer additional follow-up care. Any medical concerns pertaining to your telehealth skin cancer screening recommendation may require an in-person visit at your local medical facility or hospital. In the event of a medical emergency, please call 9-1-1 immediately. WHAT ABOUT THIRD-PARTY APPLICATIONS? Any information and services provided by third-party electronic health record applications (“Third-Party EHRs”) are the sole responsibility of Third-Party EHRs. Modern Ritual and its affiliated providers have no responsibility or liability for the information and services provided by Third-Party EHRs. Similarly, Third-Party EHRs have no responsibility or liability for the services provided by Modern Ritual and its affiliated providers. Third-Party EHRs and Modern Ritual and its affiliated providers have no agency, partnership, joint venture, or employee-employer relationship intended or created by these Terms or any relationship between these Third-Party EHRs and Modern Ritual and its affiliated providers. Any information provided by Third-Party EHRs is designed to assist licensed healthcare practitioners in caring for users and/or to serve users viewing their service as a supplement to, and not a substitute for, the expertise, skill, knowledge, and judgment of healthcare practitioners. Third-Party EHRs do not assume any responsibility for any aspect of healthcare administered with the aid of information the Third-Party EHRs provide. You should ensure that you are familiar with and approve of the terms on which the Third-Party EHRs are provided. TELEHEALTH SKIN CANCER SCREENING DISCLAIMER Dermoscopy is the examination of skin lesions with a magnifying tool, such as a dermatoscope. The tool allows a medical professional to render a *PRELIMINARY recommendation along with a non-exclusive list of POSSIBLE diagnoses. However, there are limitations to this technology. Dermoscopy cannot evaluate deep lesions (such as lymphoma) or lesions below the top layers of the skin (such as cysts, lipomas, and sarcomas). The information you may receive through the skin cancer screening services is not a substitute for an actual biopsy—where skin is removed and examined under a microscope (tissue pathology)—which renders the highest accuracy of diagnosis. Instead, it is an assessment of the likely risk of a lesion at a given point in time. You should not rely solely on this information for your care; always seek the advice of your physician or other qualified health care provider. By consenting to this document, you understand that you will be taking dermoscopic photographs of your lesion, which will be evaluated by a licensed provider. You will be given a recommendation based on your dermoscopic photograph. Nail bed lesions will not be evaluated. Skin Cancer Screening services are provided “as is” without warranties of any kind including express warranties, implied warranties, warranties of merchantability, warranties for fitness for a particular purpose, or non-infringement of intellectual property. In no event will Modern Ritual or its affiliated providers be liable to you or anyone else for any decision made or action taken in reliance on the information contained on this website, patient portal, or given during services, or for any consequential, special, or similar damages, even if advised of the possibility of such damages. *This statement has not been evaluated by the Food and Drug Administration. DO I HAVE TO CONSENT TO THIS DOCUMENT? NO. Only consent to this document if you want telehealth skin cancer screening services. If you do not understand or agree to any or all of the terms in this document, please do not consent. Without consenting, you will not be able to receive skin cancer screening services. ACKNOWLEDGEMENT OF PATIENT CONSENT TO THE USE OF TELEHEALTH SERVICES You acknowledge that you have read the Informed Consent and understand the information provided regarding telehealth. You fully agree to abide by the guidelines for participation in telehealth services. You confirm that you are located in the appropriate state, if applicable, to receive medical care via telehealth. You certify that you are a competent adult of at least 18 years of age and are not under the influence of alcohol or drugs. You attest that all of your questions regarding the services, if any, have been answered to your satisfaction. Upon request to hello@getmr.com, a copy of this Informed Consent will be emailed to you. MODERN RITUAL NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. MODERN RITUAL’S COMMITMENTS AND REQUIREMENTS We at Modern Ritual and our Affiliated Medical Practices and Providers understand that the information we collect about you and your health is personal. Keeping your health information confidential and secure is one of our most important responsibilities. We and our Affiliated Medical Practices and Providers keep a record of the treatments and services you receive on a HIPAA-secure platform. We need this record to provide you with quality service and to comply with certain legal requirements. We are committed to protecting your health information and to following all state and federal laws regarding the protection thereof. This Notice tells you how we may use or release your health information. It also tells you about your rights and Modern Ritual’s requirements concerning the use and disclosure of your health information. Modern Ritual and its Affiliated Medical Practices and Providers are required by state and federal law to maintain the privacy of your health information. We are required to give you this notice of our legal duties and privacy practices with respect to the health information that Modern Ritual and its Affiliated Medical Practices and Providers collect and maintain about you. We are required to follow the terms of this Notice that are currently in effect. This Notice describes and gives some examples of the permitted ways that your health information may be used or released. Release of your information outside of the boundaries of Modern Ritual and its Affiliated Medical Practices and Providers’ related services, payment, or operations, or as otherwise permitted by state or federal law, will be made only with your written authorization. You may revoke specific authorizations to release your health information, in writing, at any time. If you revoke an authorization, we will no longer release your health information to the authorized person, except to the extent that we have already used or released that information in reliance on your original authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the services we have provided to you. We reserve the right to revise this Notice. We reserve the right to make the revised Notice effective for health information we already have about you as well as any information we create or receive in the future. We will post a copy of the current Notice at https://www.getmr.com/ and will provide a copy of our revised Notice to you upon request. Any updated Notice will be available at https://www.getmr.com/ and by writing to: hello@getmr.com. You have the right to a paper copy of our current Notice of Privacy Practices at any time. WHO WILL FOLLOW THIS NOTICE? This Notice describes the practices of Modern Ritual and that of: ● Affiliated Medical Practices, Affiliated Medical Providers, or programs directly operated or managed by Modern Ritual ● employees, staff, and other personnel of Modern Ritual YOUR HEALTH INFORMATION RIGHTS You have the following rights regarding health information we have about you: ● RIGHT to Inspect and Obtain Copies: You have the right to inspect and obtain a copy of health information that may be used to make decisions about your treatments. Usually, this includes medical and billing records. It does not include information that is needed for civil, criminal, or administrative actions or proceedings. We may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request. To inspect or obtain a copy of your health information, you can submit your request in writing to hello@getmr.com or you can ask for a copy of your health information in person. We may deny your request to inspect and obtain a copy in very limited circumstances. If you are denied access to your health information, you may request that the denial be reviewed. A Compliance Officer will review your request and the denial. The person(s) conducting the review will not include the person who denied your request. We will comply with the outcome of the review. ● RIGHT to Amend: If you feel that the health information we have about you is incorrect or incomplete, you may ask us to amend that information. We may deny your request if you ask to amend information that: (1) was not created by us; (2) is not part of the health information kept by us; (3) is not part of the information which you would be permitted to inspect or copy; or (4) is determined to be accurate and complete. You have the right to request an amendment for as long as the information is kept by or for us. To request an amendment, your request must be made in writing and submitted to hello@getmr.com. In addition, you must provide a reason that supports your request. ● RIGHT to Accounting of Disclosures: You have the right to request a list of information releases that we have made regarding your health information. The list will not include: health information releases: (1) made for purposes of providing services to you, obtaining payment for services, or releases made for other administrative or operational purposes; (2) made for national security; (3) made to correctional and other law enforcement custodial situations; (4) made based on your written authorization; (5) made to persons who are involved in your care; or (6) made prior to April 14, 2003. To request this list or accounting of disclosures, you must submit your request in writing to hello@getmr.com. Your request must state a time period that may not be longer than six (6) years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a twelve (12) month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. ● RIGHT to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for the purpose of services or payment. You also have the right to request that we restrict or limit health information about you that we may use or disclose to someone who is involved in your care or the payment for your services, such as a family member. For example, you could ask that we not use or disclose information about the service you received to your spouse or significant other. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed for an emergency situation. To request restrictions, you may tell us in person or make your request in writing to hello@getmr.com. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse). ● RIGHT to Request Confidential Communications: You have the right to request that we communicate with you about your health matters in a certain way or at a certain location. For example, you can ask that we only contact you at a certain phone number or by mail. To request communications, you must make your request in writing to hello@getmr.com. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. ● RIGHT to a Paper Copy of this Notice: You have a right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice at hello@getmr.com. To obtain a paper copy of this Notice, you must make your request in writing to hello@getmr.com. ● Improper Disclosure Notification: In certain instances, we may be obligated to notify you (and potentially other parties) if be become aware that your health information has been improperly disclosed as determined by applicable law. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU Your health information, which includes any information that relates to your past, present, or future health condition (which might include your photograph), may be used and released by Modern Ritual and its affiliates for the purposes of providing services to you, obtaining payment for services, for administrative and operational purposes, and to evaluate the quality of the services you receive. Not all types of uses and releases can possibly be described in this document. We have listed some common examples of permitted uses and disclosures below. ● For Services: Modern Ritual may share health information about you to coordinate the services you may need, such as referrals for follow-up services. We may use health information about you to provide you with our services. ● For Operations: Modern Ritual and its Affiliated Medical Practices may use and release information about you to ensure that the services and benefits provided to you are appropriate and high quality. We may combine health information about many individuals to research health trends or determine what services and programs should be offered, or whether new services are useful. We may share your health information with our business partners who perform functions on our behalf. For example, our business partners may use your information to perform coordination of services or other assessment activities. Modern Ritual requires that our business partners abide by the same level of confidentiality and security as Modern Ritual when handling your information. ● To Keep You Informed: Unless you provide us with alternative instructions, we may contact you about reminders for appointments, services, or after-care. We may also contact you to tell you about benefits or services that may be of interest to you or to give you information about your service choices. ● To Other Government Agencies Providing Benefits or Services: We may release your health information to other government agencies that are providing you with benefits or services when the information is necessary for you to receive those benefits or services. ● As Required by Law: We will disclose health information about you when required to do so by federal, state, or local law. ● To Avert a Serious Threat to Health or Safety: We may release your health information if it is necessary to prevent a serious threat to your health, safety, or the health and safety of the public or another person. ● For Public Health Activities: We may disclose health information about you to public health agencies, subject to the provision of applicable state and federal law, for the following kinds of activities: ❖ to prevent or control disease, injury, or disability; ❖ to report child abuse or neglect to agencies authorized by law to receive these reports; ❖ to report reactions to medications or problems with products to the Food and Drug Administration (FDA); ❖ to notify people of recalls of products they may be using; ❖ to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading the disease or condition; or ❖ to notify the appropriate government authority if we believe a client has been a victim of abuse, neglect, or domestic violence; we will only make this disclosure if you agree when required or authorized by law. ● For Health Oversight Activities: Modern Ritual and its Affiliated Medical Practices and Providers may share your health information within Modern Ritual and with other agencies for oversight activities authorized by law. Examples of these oversight activities include audits, inspections, investigations, and licensure. ● Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may release health information about you in response to a court or administrative order. We may also release health information about you in response to a court order, subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information required. ● Law Enforcement: We may release health information to a law enforcement official: ❖ in response to a court order, subpoena, warrant, summons, or other similar process; ❖ to identify or locate a suspect, fugitive, material witness, or missing person; ❖ about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; or ❖ about a death we believe may have been the result of criminal conduct. ● National Security and Protection of the President: We may release your health information to an authorized federal official or other authorized persons for purposes of national security, for providing protection to the President, or to conduct special investigations, as authorized by law. ● To the Military: If you are a veteran or a current member of the armed forces, we may release your health information as required by military command or Veterans Administration authorities. If you do not object and the situation is not an emergency and disclosure is not otherwise prohibited by stricter laws, we are permitted to release your health information under the following circumstances: ● To Individuals Involved in Your Care: We may release your health information to a family member, other relative, friend, or other person who you have identified to be involved in your care. ● To Family: We may use your health information to notify a family member, a personal representative, or a person responsible for your care, of your location, general condition, or death. ● To Disaster Relief Agencies: We may release your health information to an agency authorized by law to assist in disaster relief efforts. INFORMATION NOT COVERED UNDER THIS NOTICE ● Confidential HIV Related Information: Confidential Human Immunodeficiency Virus (HIV)-related information (information concerning whether or not you have had an HIV-related test, or have HIV infection, HIV-related illness, or Acquired Immune Deficiency Syndrome (AIDS), or which could indicate that a person has been potentially exposed to HIV, can only be given to entities allowed to have it by law or allowed to have it by a release that you have signed. ● Alcohol or Substance Abuse Treatment Information: If you have received alcohol or substance abuse treatment from an alcohol/substance abuse program that receives funds from the United States government, federal regulations may protect your treatment records from disclosure without your written authorization. FOR MORE INFORMATION OR TO REPORT A PROBLEM If you believe your privacy rights have been violated, you may file a complaint with any or all of the agencies listed below. There will be no penalty or retaliation for filing a complaint: SkinVest Inc. P.O. Box 146 510 Meadowmont Village Circle Chapel Hill, NC 275171 Email: hello@getmr.com U.S. Department of Health and Human Services - Office for Civil Rights 200 Independence Avenue, S.W. Washington, D.C. 20201 Toll-Free Phone: 1-800-368-1019; TDD: 1-800-537-7697 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES You acknowledge that you have received, read, and understood this Notice of Privacy Practices for Protected Health Information for Modern Ritual and its Affiliated Medical Practices and Providers. You also acknowledge that you have read and understood how your medical information may be used and disclosed, and how you can get access to this information.