Practice & Privacy

Practice Policies

 CONSENT FOR TELEHEALTH

Signed at Every Visit

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KEY FAMILY HEALTHCARE,PLLC CONSENT FOR TELEHEALTH CONSULTATION
1. I understand that I am voluntarily engaging in a telemedicine consultation with KEY FAMILY
HEALTHCARE, PLLC.

2. I understand that the video conferencing technology and/or phone consultations will not be the
same as a direct patient/health care provider visit due to the fact that I will not be in the same room
as my health care provider.

3. I understand that a telehealth consultation has potential benefits including easier access to care,
decreasing costs, and allowing visits to be performed from the comfort of my home.

4. I understand there are potential risks to this technology, including interruptions, unauthorized
access, and technical difficulties. I understand that my health care provider or I can discontinue the
telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the
situation.

5. I understand that my healthcare information may be shared with other individuals for scheduling
and billing purposes. I understand that if there is another individual present during the telehealth
consultation that I will be informed of their presence and I will also disclose if there is another
individual with myself. It is agreed that these individuals will 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.

6. I understand that the alternative to a telemedicine consultation is to forgo evaluation and
treatment with Kathryn A. Fry, APRN,FNP-C or other Key Family Healthcare, PLLC providers and to
seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a
telemedicine consultation.

7. I understand that telemedicine has limitations in regard to the physical examination. I understand
that the physical exam portion of the care provided through Key Family Healthcare, PLLC will be
limited to inspection via video conferencing and some parts of the exam such as physical tests,
examination of certain body parts, and vital signs may not be done at all.

8. Telemedicine services offered through Key Family Healthcare,PLLC are not an Emergency
Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go
to the emergency department, or go to an urgent care.

9. To maintain my privacy, I will not share telemedicine login information or video conferencing links
with anyone unauthorized to attend the appointment.

By signing this form, I certify: ● That I have read or had this form explained/read to me and I
understand its contents including the risks and benefits of telemedicine. ● That I have had the
opportunity to ask questions and have had them answered to my satisfaction.

BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO
THE ITEMS CONTAINED IN THIS DOCUMENT.

PRACTICE POLICYSigned at First Visit Download PDF

KEY FAMILY HEALTHCARE,PLLC

Practice Policy

APPOINTMENTS AND CANCELLATIONS

The standard meeting time for visits is 15 minutes. We may request and schedule longer visits for
certain chief complaints. Due to the on-call nature of the practice, payment will be fully charged upon
scheduling. Cancellations and re-scheduled visits will be subject to a full charge if NOT RECEIVED
AT LEAST 2 HOURS IN ADVANCE. If you are late for an appointment, you may lose some of the
allotted time for that appointment. You may be considered a No-Show if you fail to log in more than
10 minutes after the start of your appointment.

ACCESSIBILITY TO YOUR PROVIDER If you need to contact Key Family Healthcare, PLLC
between sessions, please send us a message through your patient portal or at
Katie@Keyfamilyhealthcare.com. We are often not immediately available; however, we will attempt
to return your message within 24 hours. Please note that Portal Messages and emails are highly
preferable to phone calls. If a true emergency situation arises, please call 911 or go to your local
emergency room.

ELECTRONIC COMMUNICATION

We cannot ensure the confidentiality of any form of communication through electronic media,
including, but not limited to, text messages, telephone communication, the Internet, facsimile
machines, and e-mail. Telemedicine is broadly defined as the use of information technology to
deliver medical services and information between two parties that are at different locations. The
above electronic means of communication are considered telemedicine. Utilizing telemedicine
services through Key Family Healthcare, PLLC is voluntary in nature and you need to understand:

1. You have the right withhold or withdraw your consent for telemedicine services at any time. If
this occurs, we cannot provide care for you any longer as Key Family Healthcare, PLLC is strictly a
telemedicine practice.

2. We will protect your protected health information in the same fashion as a brick and mortar
practice. Data breaches can happen, and we cannot assure your information is 100% protected
although our platform is 100% HIPAA compliant.

3. We will not use your protected health information for research purposes unless you give us
consent to do so.

4. There are potential benefits, risks and subsequent consequences of telemedicine. Potential
benefits include, but are not limited to improved access to care, reducing costs, improving the
quality of visits, and reduction of travel time associated with medical visits. The medical provider
will make assessments, diagnoses, and treatment plans based on all the visual and auditory
information provided during the video conference or message appointment. This is limited and posts
potential risks including, but not limited to the provider’s inability to make complete diagnostic
assessments that might require a physical exam and to see the patient in person. During an
in-person encounter, a medical provider has the ability to see the entire patient including but not
limited to their gait, smell, general appearance, and demeanor. Potential consequences thus include
the provider not being aware of clinically significant information that you may not recognize as
significant to present verbally to the provider.

MEDICARE & MEDICAID PATIENTS

You recognize that as a Medicaid recipient, any service covered by Medicaid is unable to be utilized
as a

cash pay service. You understand that by using the telehealth services offered by Key Family
Healthcare, PLLC, you may forfeit your state-covered benefits and be subject to fines and removal of
your coverage according to your individual plan requirements. Key Family Healthcare, PLLC does
not offer Medicaid covered service. Key Family Healthcare, PLLC is opted out of Medicare service.
Medicare recipients are able to pay cash for services according to their individual plan requirements,
but Medicare will not reimburse or cover any services that you opt to receive through cash payment.
It is the patient’s responsibility to understand
the requirements and limitations of your respective plan.
MINORS

We require parental consent for all visits done through telemedicine. We require your parents to be
present

during a portion of the visit to ensure that they are consenting to treatment. ALL MINORS MUST
HAVE A PRIMARY CARE PROVIDER LISTED. If you are a minor, your parents may be legally
entitled to some information about your treatment. We will discuss with you and your parents what
information is appropriate for them to receive and which issues are more appropriately kept
confidential.

REFUNDS

Requests for refund will be evaluated on an individual basis. Because we use the most current
guidelines, no refunds will be issued for dissatisfaction with clinical outcome, prescription or
available technology. No refunds will be available for No-Show appointments.
TERMINATION

We can terminate treatment with you at any time. We will not terminate the medical relationship with
you without first discussing and exploring the reasons and purpose of terminating. If treatment is
terminated for any reason, we will provide you with a list of qualified providers to continue your care.
You may also choose someone on your own or from another referral source. Should you fail to not
show up for your follow up appointments, not obtain lab work in a timely fashion or are
non-compliant with treatment, unless other arrangements have been made in advance, for legal and
ethical reasons, we must consider the professional relationship discontinued. Please be advised that
we have a zero tolerance policy for abuse of staff and providers. We have the right to dismiss
immediately and terminate appointments with no refund for verbal abuse of staff and providers.

PRIVACY POLICYSigned at First Visit Download PDFKey Family Healthcare,PLLC

Privacy Policy

OUR LEGAL RESPONSIBILITIES

We are required by law to give you this notice. It provides you on how we may use and disclose
protected health information about you and describes your rights and our obligations regarding
the use and disclosure of that information. We shall maintain the privacy of protected health
information and provide you with notice of our legal duties and privacy practices with respect to
your protected health information. We have the right to change these policies at any time. If we
change our privacy policies, we will notify you of these changes immediately. This current policy is in
effect unless stated otherwise. If the policy is changed, it will apply to all your current and past health
information. You may download a copy of this policy at anytime at www.www.keyfamilyhealthcare.com

HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION

The following examples describe how we may use your protected health information for
your treatment, payments, healthcare operations etc. Please be advised that not every use or
disclosure in a particular category will be listed.

Treatment: We may use and disclose your protected health information to provide you
treatment. This includes disclosing your protected health information to other medical providers,
trainees, therapists, medical and office staff that are involved in your health care.
For example, your medical provider might need to consult with another provider to coordinate
your care. Also, the office staff may need to use and disclose your protected health information
to other individuals outside of our office such as the pharmacy when a prescription is called in or the
lab for lab orders.

Payment: Your protected health information may also be used to obtain payment from an
insurance company or another third party. This may include providing an insurance company your
protected health information for a pre-authorization for a medication we prescribed.
Health Care Operations: We may use or disclose your protected health information in order to
operate this medical practice. These activities include training students, reviewing cases with
employees, utilizing your information to improve the quality of care, and contacting you by
telephone, email, or text to remind you of your appointments. We may also use and disclose your
protected health information for marketing activities. For example, we might send you a thank you
card in the mail with a coupon for specialized services or products. We may also send you
information about products or services that might be of interest to you. You can contact us at any
point to stop receiving this information.

We will not use or disclose your protected health information for any purpose other than those
identified in this policy without your specific, written Authorization. You may give us written
authorization to use your protected health information or to disclose it to anyone for any purpose.
You can revoke this authorization at any time but will not affect the protected health information
that was shared while the authorization was in effect.

Appointment Reminders: We may contact you as a reminder that you have an appointment for
your initial visit, follow up visit, or lab work via text, phone or email.

Others Involved in Your Health Care: We may disclose protected health information about
you to your family members or friends if we obtain your verbal agreement to do so, or if we give
you an opportunity to object to such a disclosure and you do not raise an objection. For example,
we may assume that if your spouse or friend is present during your evaluation, that we can
disclose protected professional information to this person. If you are unable to agree or object to
such a disclosure, we may disclose such information as necessary if we determine that it is in
your best interest based on our professional judgment if there is an urgent or emergent need.
Research; We will not use or disclose your health information for research purposes unless you
give us authorization to do so.

Organ Donation: If you are an organ donor, we may release protected health information to
organizations that handle organ procurement or organ, eye or tissue transplantation if it is
necessary to facilitate this process.

Public Health Risks: We may disclose your protected health information, if necessary, in order
to prevent or control disease, report adverse events from medications or products, prevent injury,
disability or death. This information may be disclosed to healthcare systems, government
agencies, or public health authorities. We may have to disclose your protected health information
to the Food and Drug Administration to report adverse events, defects, problems, enable recalls
etc. if required by FDA regulation.

Health Oversight Activities: We may disclose protected health information to health oversight
agencies for audits, investigations, inspections or licensing purposes. These disclosures might be
necessary for state and federal agencies to monitor healthcare systems and compliance with civil
law.

Required by Law: We will disclose protected health information about you when required to do
so by federal, state and/or local law.

Workman’s Compensation: We may disclose your protected health information to workman’s
comp or similar programs.

Lawsuits: We may disclose your protected health information in response to a court action,
administrative action or a subpoena.

Law Enforcement: We may release protected health information to a law enforcement official in
response to a court order, subpoena, warrant, subject to all applicable legal requirements.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Access to medical records: You have the right to access and receive copies of your protected
health information that we use to make decisions about your care. We may charge a fee for printed
copies of this information. All information will be available at no charge in your portal.
Amendment: If you believe the protected health information we have about you is incorrect or
incomplete, you may ask us to amend the information You will need to submit a written request
on why you feel the health information should be amended. We may deny your request to amend
if you did not send a written request or give a reason on why it should be amended. If we deny
your request, we will provide you a written explanation. We may deny your request if we believe
the protected health information is accurate and complete.

Accounting of Disclosures: You have the right to receive a list of instances in which we
disclosed your personal health information unless the disclosure was used for treatment,
payment, healthcare operations, was pursuant to a valid authorization and as otherwise provided
in applicable federal and state laws and regulations. You must submit a written request to obtain
this “accounting of disclosures” to the individual listed at the bottom of this policy. After your
request has been approved, we will provide you the dates of the disclosure, the name of the
individual or entity we disclosed the information to, a description of the information that was
disclosed, the reason why it was disclosed, and any additional pertinent information. This
information may not be longer than six years ago prior to the date the accounting is requested.
We reserve the right to charge a reasonable fee for this process.

Restriction Requests: You have the right to request in writing a restriction or limitation on the
protected

health information we use or disclose about you for treatment, payment, or healthcare operations.
We shall accommodate your request except where the disclosure is required by law.

Confidential Communication: You have the right to request that we communicate with you
about healthcare matters in a certain way and at a certain location. We must accommodate your
request if it is reasonable and allows us to continue to collect payments and bill you.

Paper copy of this notice: You may request a hard copy of this practice policy if you reviewed
and signed it via electronic means. To obtain this copy, contact the individual at the end of this
privacy policy.

Complaints: If you believe your privacy rights have been violated, you may file a complaint
with our office. You also file a complaint with the U.S. Department of Health and Human
Services. We will provide you with the address to file your complaint with the U.S. Department
of Health and Human Services upon request.

FLORIDA TELEHEALTHThis practice is authorized to practice telehealth in the State of FL in accordance with State Law.
https://flhealthsource.gov/telehealth/

Privacy Policy

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