TRIPMEDRX, INC.—CONSENT TO TELEHEALTH
Last Updated: 06-20-2023
Thank you for your interest in TripMedRx. Welcome! We, TripMedRx (also referred in this document as “us”, “we”, or “our”) provide you with personalized pre-travel medical advice in the form of general medication and vaccination recommendations based on your destination(s), health history, planned activities and the type of traveler you are (the “Travel Medicine Offerings”).
Because we provide the Travel Medicine Offerings using electronic communications, information technology, or other means between a health care provider and a patient who are not in the same physical location (“Telehealth”), this Informed Consent explains the risks, benefits, alternatives, and certain limitations of using Telehealth to receive medical care. Telehealth allows you to receive health care service in the convenience of your home. However, there are potential limitations (for example, we could find the information you transmitted is insufficient to make a medical decision, meaning you will have to go in-person to a different provider, or that despite our strong security measures, your information could be breached by a bad actor). Also, because we cannot physically examine you in-person, there is a chance that certain diagnoses or issues could be missed and risk causing you significant bodily harm, or death.
Informed Consent to Participate in Telehealth Consultation
The Travel Medicine Offerings are not intended for the provision of clinical diagnosis requiring an in-person evaluation and you should not use it if you need immediate/urgent care. We do not provide emergency medical consultation or prescribe any controlled substances.
When in doubt, please call 911 or contact your local in-person healthcare professionals immediately.
Do not disregard, avoid, or delay in obtaining in-person care from your doctor or other qualified professional because of information or advice you received through the Travel Medicine Offerings.
If you are thinking about suicide or if you are considering harming yourself or others or if you feel that any other person may be in any danger or if you have any medical emergency, you must immediately call the emergency service number (911 in the U.S.) and notify the relevant authorities. Seek immediate in-person assistance.
Travel Medicine Offerings
The Travel Medicine Offerings may include chart review, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for patient assessment and education, and may include any combination of the following: (1) review of health records and other information about your planned travel; (2) interactive, asynchronous or synchronous chat, audio, and/or video communications; and (3) live two-way audio and video.
Limitations
The scope of the Travel Medicine Offerings are limited to a consultation and review of your medical information to advise you on travel best practices based on your specific destinations, itinerary, methods of travel, current physical condition, and other factors. Any provider-patient relationship formed between you and us is limited solely to the Travel Medicine Offerings and does not create any obligation that we engage in an ongoing provider-patient relationship with you, even if you choose to engage us for multiple consultations, either ad-hoc, or through a retainer or subscription plan made available through the Site. You expressly agree that we are under no obligation to follow up, review additional records, or provide additional services outside of or following the completion of the Travel Medicine Offerings. You should not change your treatment or care plan, medication or therapy based on information you received through the Travel Medicine Offerings.
The Travel Medicine Offerings are supplemental to any treatment or care provided by your primary care provider or other healthcare professionals that you work wit and should not replace regular medical visits with those providers. Always seek the advice of your own doctor regarding your medical conditions or the use (or frequency) of any medication or medical device. Questions regarding any drug, device or treatment always should be directed to your doctor. Never disregard professional medical advice or delay in seeking it because of information you have received in connection with our services. Always consult with your healthcare professional if you have any questions or concerns about your health or condition or experience any changes in your condition or health status. We do not provide emergency services, time sensitive or urgent, remote or critical care services.
Expected Benefits
Improved access to care by enabling you to remain in your home while we provide the Travel Medicine Offerings.
More efficient care evaluation.
Obtaining the specialist expertise that we provide.
Possible Risks
Delays in evaluation due to deficiencies or failures of the equipment and technologies used to provide Telehealth.
The inability to conduct an in-person physical examination could result in incomplete information used to provide care.
We may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or requiring you to meet with a local in-person provider.
A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other errors.
Security protocols could fail, causing a breach of privacy or personal medical information including but not limited to your contact information, protected health information, or mental health information.
Medical Information and Records
All laws applicable to medical records privacy and access apply to Telehealth. Dissemination of any patient identifiable images or information from your telemedicine visit require your consent. Our Notice of Privacy Practices describes how we protect, use, and disclos medical information about you and how you can get access to this information.
Confidentiality
All existing confidentiality protections under federal and state law apply to information used or disclosed during your Telehealth visit and any subsequent interactions.
Duties and Obligations
Providers have certain duties and obligations that may require the disclosure of your confidential information under certain situations, including, but not limited to:
A duty to warn about serious harm to myself.
A duty to warn about serious harm to others.
An obligation to report to the appropriate state agency current child abuse or neglect, elderly abuse, or otherwise disabled individual abuse.
An obligation to respond to a valid subpoena or court order seeking the disclosure of my records.
Rights
You may withhold or withdraw your consent to Telehealth at any time before and/or during the consult.
By accepting this consent, you acknowledge your understanding and agreement to the following:
I understand that if I am concerned that I may be experiencing a medical emergency or that I may require urgent care, I should call 9-1-1 immediately and that TripMedRx are not an appropriate place to receive care nor is TripMedRx able to connect me directly to any local emergency services.
I hereby consent to receiving TripMedRx’s services via Telehealth. I understand that TripMedRx offers Telehealth-based medical services, but that these services do not replace the relationship between me and any in-person doctor that I see.
I understand there is a risk of technical failures during the Telehealth encounter beyond the control of the TripMedRx. I agree to hold harmless TripMedRx for delays in evaluation or for information lost due to such technical failures.
I understand that I have the right to withhold or withdraw my consent to the use of Telehealth in the course of the Travel Medicine Offering at any time, without affecting my right to engage TripMedRx to provide the Travel Medicine Offerings to me in the future. I understand that I may suspend or terminate use of the Telehealth services at any time for any reason or for no reason without affecting my right to future use of the Travel Medicine Offerings.
I understand that I may expect the anticipated benefits from the use of Telehealth in my care but that no results can be guaranteed or assured.
I understand that if I participate in a Telehealth consultation, that I have the right to request a copy of my medical records which will be provided to me at the reasonable cost of preparation, shipping, and delivery.
I understand that the laws that protect privacy and the confidentiality of medical information also apply to Telehealth, and that information obtained in the use of Telehealth which identifies me will be used and disclosed in accordance with TripMedRx’s HIPAA Notice of Privacy Practices.
TripMedRx will give you an opportunity to ask questions about this information and ensure all of your questions have been answered.
TRIPMEDRX, INC. -- HIPAA NOTICE OF PRIVACY PRACTICES
1701 U Street
Sacramento, CA 95818
www.tripmedrx.com
Your Information. Your Rights. Our Responsibilities.
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.
Your Rights
You have the right to:
Request a copy of your paper or electronic medical record.
Correct your paper or electronic medical record.
Request confidential communication.
Ask us to limit the information we share.
Request a list of those with whom we’ve shared your information.
Request a paper copy of this privacy notice.
Choose someone to act for you.
File a complaint if you believe your privacy rights have been violated.
Your Choices
You have some choices in the way that we use and share information as we:
Tell family and friends about your condition.
Market our services and sell your information.
Our Uses and Disclosures
We may use and share your information as we:
Treat you.
Run our organization.
Bill for your services.
Help with public health and safety issues.
Do research.
Comply with the law.
Respond to organ and tissue donation requests.
Work with a medical examiner or funeral director.
Address workers’ compensation, law enforcement, and other government requests.
Respond to lawsuits and legal actions.
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. You can ask us how to exercise any of these rights, or any other HIPAA-related questions by contacting us at
1701 U Street
Sacramento, CA 95818
www.tripmedrx.com
Request an electronic or paper copy of your medical record.
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record.
You can ask us to correct health information about you that you think is incorrect or incomplete.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share.
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information.
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice.
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you.
If you have a health care directive and have given someone authority to make medical decisions for you, or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated.
You can complain if you feel we have violated your rights by contacting us using the information at the top of bottom of this Notice.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
Share information with your family, close friends, or others involved in your care.
Share information in a disaster relief situation.
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases, we never share your information unless you give us written permission:
Marketing purposes
Sale of your information
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Treatment
We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Operations of our organization.
We can use and share your health information to operate and run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues.
We can share health information about you for certain situations such as (but not limited to):
Preventing diseases or spread of various illnesses.
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety.
Do research.
We can use or share your information for health research.
Comply with the law.
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests.
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions.
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
Other obligations or uses of your health information that do not apply to our practice.
We do not:
Bill public or private insurance or other third-party payors for the services that we provide.
Regularly keep or maintain psychotherapy notes.
Create or manage a hospital directory
Our Responsibilities
We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.
Effective Date
This HIPAA Notice of Privacy Practices is effective as of 06-20-2023.