Telehealth involves the use of secure electronic communications, information technology, or other means to enable a healthcare provider and a patient at different locations to communicate and share individual patient health information for the purpose of rendering clinical care. This “Telehealth Informed Consent” informs the patient (“patient”, “you”, or “your”) concerning the treatment methods, risks, and limitations of using a telehealth platform.
Services Provided:
Telehealth services may be provided through one or more of the following medical groups: VH Provider Group, P.A., Daniel Bensimhon, M.D., P.C., and VH Provider Group of NJ P.C. (collectively, “Group”), and the Group’s engaged providers (our “Providers” or your “Provider”). The Group and Providers receive technical and administrative support from Ventricle Health, Inc., which operates the telehealth platform through which the services are provided. The telehealth services may include a patient consultation, diagnosis, treatment recommendation, remote patient monitoring, prescription, and/or a referral to in-person care, as determined clinically appropriate (the “Services”).
When using our telehealth services, you will be treated by a licensed physician/cardiologist, registered nurses, health advocates, and other healthcare professionals who will be part of your clinical care team.
Unless we provide specific authorization to you, you must be physically located in your state of residence (as enrolled with your health plan) during your scheduled telemedicine consultation. This will ensure that you are appropriately matched with a licensed physician that can treat, diagnose and prescribe medications if applicable.
You understand and agree with the following:
You have read and understand the information provided above regarding telehealth services, have been provided opportunities to discuss it with your Provider or designated care team, and all of your questions have been answered to your satisfaction. You hereby give your informed consent for the use of telehealth in your medical care.
Complaint Policy
All patients have the right to communicate grievances regarding their care. Should you wish to make a formal complaint about one of your care providers you may do so in writing and submit the concern to the Group at compliance@ventriclehealth.com.
Additional State-Specific Consents: The following consents apply to patients accessing our website for the purposes of participating in a telehealth consultation as required by the states listed below:
Alaska: you have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.
California: you have been informed of the following notices: 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.
NOTICE TO PATIENTS Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint here, email: licensecheck@mbc.ca.gov, or call (800) 633-2322.
Iowa: you have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.
Indiana: you have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.
Kentucky: you have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here (or, alternatively, by accessing this URL in my browser: kbml.ky.gov/grievances/Pages/default.aspx ).
Maine: you have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here; Or, the Maine Board of Osteopathic Licensure’s website, here.
Oregon: you have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.
Rhode Island: you have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here.
Texas: you have been informed of the following notice:
NOTICE CONCERNING COMPLAINTS -Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353, For more information, please visit our website at www.tmb.state.tx.us. AVISO SOBRE LAS QUEJAS- Las quejas sobre médicos, asi como sobre otros profesionales acreditados e inscritos del Consejo Médico de Tejas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugia, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board, Attention: Investigations, 333 Guadalupe, Tower 3, Suite 610, P.O. Box 2018, MC-263, Austin, Texas 78768-2018, Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353, Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us
Vermont: you have been informed that if you want to register a formal complaint about a provider, you should visit the medical board’s website, here; Or, the Vermont Board of Osteopathic Examiners’ website, here. You understand that you may be presented with the option to receive services in person, through telehealth, or by audio-only telephone, to the extent clinically appropriate. In the event you receive services by using audio-only telephone, it will be your choice to do so, but you are not prevented from receiving services in person or through telehealth at a later date. Opportunities and limitations of delivering and receiving health care services using audio-only telephone include: convenience and access to care from any location with phone service, but can also reduce the amount of information that is available to your Provider (e.g., such as the availability of medical images, clinical records, etc.). If the Group is enrolled with your health insurance plan, the services delivered by audio-only telephone will be billed to your health insurance plan, if appropriate. In the event the audio-only services are billed to your health insurance plan, you acknowledge you are financially responsible for any applicable co-payments, coinsurance, and deductibles, and you understand that not all audio-only health care services are covered by all health plans.
Effective Date: November 27, 2023
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.
This notice is issued on behalf of VH Provider Group, P.A., Daniel Bensimhon, M.D., P.C., and VH Provider Group of NJ P.C. (collectively, “Group”) when practicing on or in connection with the Ventricle Health platform.
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, and on our website.
Your Rights
You have the right to:
Your Choices
You have some choices in the way that we use and share information as we:
Our Uses and Disclosures
We may use and share your information as we:
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. To exercise any of your rights listed below, please submit a written request to:
Compliance and Privacy Office
1150 Revolution Mill Dr.
Suite 6
Greensboro, NC 27405
Or
Email: compliance@ventriclehealth.com
Get an electronic or paper copy of your medical record
Ask us to correct your medical record
Request confidential communications
Ask us to limit what we use or share
Get a list of those with whom we’ve shared information
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
File a complaint if you feel your rights are violated
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:
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:
In the case of fundraising:
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.
Treat you
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.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your 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:
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:
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.
Our Responsibilities
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Health Information Exchange (HIE) Participation
Participation in Zus Health
The Group uses the Zus Platform to connect to other healthcare organizations and networks (which are altogether called the “Zus Network”) to facilitate the secure exchange of your health information between and among your health care providers for the purposes related to treatment, payment, healthcare operations, and secondary use. Organizations can connect to Zus directly or through other systems like a provider’s electronic health record in order to send or receive your health information.Through our connection to the Zus Network, we will share your health information, such as summaries of your doctor visits, clinical notes, allergies, medications, diagnoses, past lab test results, a list of your treating providers, your plan of care, and other similar information with other participating health care providers to provide faster access, facilitate better coordination of care, and enable more informed care decisions.
Zus strictly limits who can access your health information as required by HIPAA and other applicable state and federal privacy laws. Zus only allows a healthcare organization to receive or send your information if they are permitted to do so under HIPAA and if the organization has a direct relationship with you (i.e., as a “HIPAA Covered Entity”) or an indirect relationship (i.e., as a “HIPAA Business Associate”) for purposes of providing healthcare services to you.
Your participation is voluntary and at any time you can stop Zus from sharing your information with other healthcare organizations by “opting out” of the Zus Network.You may choose to opt-out and not have any of your information shared through the Network by completing and submitting the Zus Request to Opt Out Form. Your request to opt out will be effective five (5) to seven (7) business days after you submit your request to Zus. Please note that any of your health information that Zus has already shared before your Request to Opt Out is effective will remain with those organizations that received it. You can opt back in to sharing information through Zus by completing the Zus Request to Opt In Form. For additional information, please email privacy@ventriclehealth.com.
Participation in NC HealthConnex
Our organization participates in the North Carolina Health Information Exchange Network, known as NC HealthConnex, which is operated by the North Carolina Health Information Exchange Authority (NC HIEA). We will share your protected health information (PHI) with NC HealthConnex and may use NC HealthConnex to access your PHI to assist us in providing health care to you. We are required by law to submit clinical and demographic data for services paid for by North Carolina state programs such as Medicaid or the State Health Plan. We may also share other patient data with NC HealthConnex not paid for with state funds.
Your Right to Opt Out
If you do not want NC HealthConnex to share your PHI with other health care providers participating in NC HealthConnex, you may opt out by submitting a form directly to the NC HIEA. The Opt-Out Form and instructions are available at NCHealthConnex.gov/patients. Please note that even if you opt out, we are still required to submit your PHI to NC HealthConnex for health care services paid for by state programs. Your patient data may also be exchanged or used by the NC HIEA for public health or research purposes as permitted or required by law.
For more information about NC HealthConnex or your privacy rights, please contact our Privacy Officer or visit NCHealthConnex.gov.