Informed Consent and HIPAA Release
Sniffle Health Inc. (Sniffle or we) operates a website and a mobile application that provide a synchronous audio/video communication platform (Sniffle Platform) through which physicians can practice telemedicine. By creating a user account with Sniffle and requesting a telehealth and/or telemedicine consultation with a participating physician, you are requesting to enter into a doctor/patient relationship with that physician who will provide you with healthcare services through the Sniffle Platform.
You acknowledge that the Physician you choose will provide professional medical services to you. You understand and agree that Sniffle will not provide medical services to you. Sniffle provides only certain technology and administrative services such as scheduling your telemedicine consultation and providing the medium through you and your Physician communicate. Unless payment arrangements have been established prior through your physician, employer, association, or other entity, each time you schedule a consultation, you agree to pay Sniffle an appointment scheduling fee at the time you request the appointment.
As a requirement of the subscribing Physicians, you agree to complete a medical history form that Sniffle will store electronically and make available to each Physician who performs a telemedicine consultation with you. You understand that a Physician may require that you update your medical history during or prior to a consultation.
You acknowledge that, if a Physician, who is not your primary care physician, consults with you through the Sniffle Platform, the resulting patient/physician relationship with that Physician is not intended to replace your relationship with your primary care physician. Furthermore, you agree that, by requesting a telemedicine consultation with a Physician through the Sniffle Platform, you are designating that Physician as your physician because your primary care (or other) physician, as applicable, could not meet your requested appointment time or is otherwise unavailable.
You acknowledge that Physicians will not prescribe any DEA (Drug Enforcement Agency) controlled substances through the Sniffle Platform. You also acknowledge that a Physician does not guarantee that a prescription will be issued during your consultation. And, further, you acknowledge that Sniffle does not guarantee that you will be treated as a patient by your chosen Physician if, for example, the Physician determines that your medical condition cannot be properly treated by him/her or through the Sniffle Platform.
If a Physician consults with you through the Sniffle Platform, you have the right to request your medical records from that Physician in accordance with applicable law.
The telemedicine services provided by the Physicians (and the technology and non-medical operational and administrative services provided by Sniffle that are attendant thereto) may involve the use of electronic communications to enable a Physician at a distant location to access your patient medical information for the purpose of providing you patient care. The information may be used for diagnosis, treatment, billing, follow-up, and/or education, and may include any or all of the following:
Patient medical records;
Live two-way audio and/or video;
Output data from medical devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Some Possible Risks:
As with any medical procedure, and in addition to the normal risks inherent with in-person medical care, there are potential additional risks associated with the use of telemedicine. These risks include, but are not be limited to:
The Physician or attending care giver may determine that the transmitted information is of inadequate quality, necessitating that you obtain an in-office, face-to-face evaluation with a physician, or reschedule a web video consultation;
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the Physician’s equipment, your mobile device or computer, the Sniffle Platform, the telecommunication carrier’s service/equipment, or internet connectivity;
Security protocols could fail, causing a breach of privacy of personal medical information;
A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
By checking the box associated with “Informed Consent” you acknowledge that you understand and agree with the following:
I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained through the use of telemedicine that identifies me will be disclosed to researchers or other entities without my written consent.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
I understand the alternatives to telemedicine consultation as they have been explained to me, and in choosing to participate in a telemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at my location, or at a testing facility, at the direction of the consulting healthcare provider.
I understand that telemedicine may involve electronic communication of my personal medical information to medical practitioners who may be located in other areas, including out of state.
I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
I understand that my healthcare information may be shared with other individuals or entities for scheduling and billing purposes. Others may also be present during the consultation other than the consulting healthcare provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time.
HIPAA Privacy Authorization
Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**
I authorize Sniffle Health Inc including those physicians who subscribe to the Sniffle Health Service and software (healthcare provider) to use and disclose the protected health information described below. By Clicking Agree and Continue I hereby give my consent to Sniffle Health and the physicians who are subscribed to the Sniffle Health platform whom I am making my appointment with to share my Protected Health Information.
**2. Effective Period**
This authorization for release of information covers the period of healthcare all past, present, and future periods.
**3. Extent of Authorization**
I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS and treatment of alcohol or drug abuse).
- This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes.
- This authorization shall be in force and effect until such time I retract such authorization in writing.
- I understand that I have the right to revoke this authorization, in writing, at anytime. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
- I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
- I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Patient Consent To The Use of Telehealth and/or Telemedicine and HIPAA Release
I have read this Informed Consent and HIPAA Release form carefully (or have had it read carefully to me), and I understand the information provided in it. I understand the risks and benefits of telehealth and/or telemedicine, and that I will have the opportunity to ask any questions I may have regarding it with the consulting physician at the onset of and during my consultation, and I can end the consultation at any time should any of my questions not be answered to my satisfaction.
I hereby give my informed consent to participate in telemedicine visits through the Sniffle Platform under the terms described in this consent and HIPAA Release form.
By clicking ‘Agree and Continue’, I hereby state that I have read this Informed Consent and HIPAA Release form carefully (or have had it read carefully to me), I agree to its terms, and wish to proceed with my consultation.