TERMS OF USE AND PRIVACY POLICY

DO NOT USE THIS SITE FOR EMERGENCY MEDICAL NEEDS. IF YOU EXPERIENCE A MEDICAL EMERGENCY, CALL 9-1-1 IMMEDIATELY.

Effective July 11, 2017

YOUR USE OF THIS APPLICATION IS CONDITIONED UPON YOUR ACCEPTANCE OF THE FOLLOWING: (1) TERMS AND CONDITIONS OF USE AND PRIVACY POLICY; AND (2) PATIENT ACKNOWLEDGMENT AND CONSENT. BY CLICKING THE "AGREE" CHECKBOX WHICH FOLLOWS, YOU ARE INDICATING YOUR ACCEPTANCE OF ALL TERMS AND AGREE TO BE BOUND BY THE TERMS AND CONDITIONS OF THESE TERMS OF USE.

IF YOU DO NOT AGREE TO THESE TERMS AND CONDITIONS OR THE PATIENT ACKNOWLEDGMENT AND CONSENT, YOU ARE NOT AUTHORIZED TO ACCESS OR USE THIS WEBSITE.

Welcome to Jupiter Medical Center's CareAnywhere telemedicine service (the "Service"). To use this Service you must agree to be bound by all terms of use of this Terms of Use and Privacy Policy (at times herein, "Agreement").

Jupiter Medical Center ("JMC") may, from time to time, at its convenience, change the terms of this Agreement. It is your responsibility to review these terms each time you use this website.

PLEASE READ THESE TERMS OF USE CAREFULLY AS IT CONTAINS IMPORTANT INFORMATION ABOUT YOUR USE OF THIS SERVICE.

TERMS OF USE

1. Patient's Physical Location. You hereby certify that you are physically located in the State of Florida. You acknowledge that your ability to access and use the Service is conditioned upon the truthfulness of this certification and that the providers you access are relying upon this certification in order to interact with you. In the event that your certification is inaccurate, you agree to indemnify JMC, its third party technology platform provider and the providers you interact with from any resulting damages, costs or claims.

2. Overview of Telemedicine Services.

(a) Telemedicine involves the use of electronic communications to enable health care providers at sites remote from patients to provide consultative services. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for consultation, diagnosis, therapy, follow-up and/or education, and may include live two-way audio and video and other materials (e.g. medical records, data from medical devices).

(b) The communications systems used will incorporate network and software protocols to protect the confidentiality of patient information and will include reasonable measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

(c) An encounter summary will be provided to the patient at the end of each encounter which may be kept for the patient's records and may be shared with other Providers for treatment purposes or as otherwise permitted or required by law.

(d) Telemedicine services you receive from Providers are not intended to replace a primary care physician relationship or be your permanent medical home. You should seek emergency help or follow-up care when recommended by a Provider or when otherwise needed, and continue to consult with your primary care physician and other healthcare professionals as recommended. We may make arrangements for follow up care either through the telemedicine Provider, a health systems partner, or other healthcare providers.

3. Anticipated Benefits of Telemedicine. The following anticipated benefits of telemedicine is not a guarantee that such anticipated benefits will apply to your specific situation:

(a) Improved access to medical care by enabling a patient to remain at his or her home or office while consulting a clinician; and

(b) More efficient medical evaluation and management.

4. Possible Risks of Telemedicine. As with any medical procedure or services, there are potential risks associated with the use of telemedicine. These risks may include, but not be limited to, to following:

(a) Delays in medical evaluation and consultation or treatment may occur due to the deficiencies or failures of the equipment used in the telemedicine process (in some instances information transmitted may be of insufficient quality to allow for appropriate medical or health care decision making by the Provider (i.e., poor resolution images, etc.));

(b) Security protocols could fail, causing a breach of privacy or personal medical information;

(c) Lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other negative outcomes; and/or

(d) Such other medical risks (including, but not limited to, misdiagnosis) which may arise as a result of a medical evaluation which is performed online via a telemedicine platform, rather than in person.

5. Acceptance of Risks. By accepting these terms, you are expressly accepting the possible risks of telemedicine more thoroughly described in the directly preceding Section 4 and you acknowledge that you understand and agree with the following:

(a) While you may expect the anticipated benefits from the use of telemedicine in your care, there is not guarantee or assurance that you will receive the anticipated results;

(b) The laws that protect the privacy and security of health information apply to telemedicine and you have received JMC's privacy practices which describe these protection(s) in more detail;

(c) You are fully responsible for payment regardless of whether the Provider who consults with and/or treats you via telemedicine requires you to follow up with a health care practitioner for an in-office visit; and

(d) You understand that your Provider, in his or her sole discretion and professional judgment, may determine that telemedicine services are not appropriate for some or all of your treatment needs and, accordingly, may elect not to provide telemedicine services to you through the telemedicine platform.

7. Security.

(a) JMC, through its third party technology platform provider, has implemented a variety of commercially standard encryption and security technologies and procedures to protect your personal information which is stored in its computer systems from unauthorized access. We also maintain standard physical and electronic procedural safeguards that limit access to your personal information to our employees (or people working on our behalf and under confidentiality agreements) who, through the course of standard business activities, need to access your personal information.

(b) Access to the Service is enabled only by usernames and passwords. You should maintain your username and password in strict confidence. In no event should you share your username or password with any third party or allow another person to access the Service using your username and password. Please notify JMC if you have any reason to believe that your username or password has been lost or compromised or misused in any way. You are fully and solely responsible for any and all use of the Service using your username and password. JMC reserves the right to revoke or deactivate your username and password at any time and for any reason.

8. Accessing the Service.

(a) To access the Service, you must first provide certain personal information, and validate your identity (or that of your minor child) and location. With the exception of minor children of whom you are a parent or legal guardian, you agree that you will not enter personal/user information for anyone other than yourself without first receiving permission from the other person. In exchange for your use of the Service, you agree to:

i. provide true, accurate, current and complete information about yourself as prompted by our registration form; and

ii. each time you use this platform, you will provide accurate, current, and complete information.

(b) JMC may contact you by telephone, mail or e-mail to verify your information. JMC may request further information from you and you agree to provide such further information to ensure you have not fraudulently registered to use the Service. If you do not provide this information in the manner requested within fourteen (14) days of the request, JMC reserves the right to suspend, discontinue, or deny you access to and use of the Services until the information is provided to JMC as requested.

(c) If you provide any information that is untrue, inaccurate, not current, or incomplete, or if we have reasonable grounds to suspect that such information is untrue, inaccurate, not current or incomplete, we reserve the right to refuse any and all current or future use of the Service. You represent and warrant that you are at least 18 years of age and possess the legal right and ability, on behalf of yourself or a minor child of whom you are a parent or legal guardian, to agree to these Terms of Use.

9. Limitations on Use.

(a) You agree that you will not use the Service(s) for any service that must be provided to you by your regular physician as a follow-up to and in-office visit.

(b) You further agree not to access or use the Service in an unlawful or illegitimate purpose or in any manner that contravenes these Terms of Use:

i. You shall not electronically record the Service in any manner;

ii. You shall not transmit:

(1) information under a false name;

(2) information that is unlawful, libelous, defamatory, obscene, fraudulent, predatory of minors, harassing, threatening or hateful to any person; or

(3) information that infringes or violated any of the intellectual property rights of others or the privacy or publicity rights of others.

iii. You shall not attempt to disrupt the operation of the Service by any method, including through use of viruses, Trojan horses, worms, time bombs, denial of service attacks, flooding, spamming, or any other computer programming or code, that exists now or may exist in the future, that is designed or intended to damage, destroy, intercept, download, interfere, manipulate, or otherwise interrupt or expropriate the Site or the Services;

iv. You shall not use the Service in any manner that could damage, disable or impair the Service;

v. You shall not attempt to gain unauthorized access to any user accounts or information, or computer systems or networks, through hacking, password mining or any other means which may exist now or in the future;

vi. You shall not use any robot, scraper or other means to access the Service for any purpose;

vii. You will not harvest or collect Protected Health Information about any other individual who uses the Service.

viii. You shall not attempt to reverse engineer, reverse assemble, reverse compile, decompile, disassemble, translate or otherwise alter, defraud or create false results from any executable code, or information on or received by this Service;

ix. You agree that any information you provide or use in accessing the Services, and your use of the Services will not infringe or facilitate infringement on any copyright, patent, trademark, trade secret, or other proprietary, publicity, or privacy rights of any party, including such rights of third parties.

(c) JMC maintains the right to delete any information provided by you that it deems, in its sole discretion, fraudulent, abusive, defamatory, and obscene or in violation of a copyright, trademark or other intellectual property or ownership right of any other person;

(d) Customer-specific information provided by you in connection with Services shall be governed by the JMC Privacy Policy which much also be reviewed, accepted, and agreed to by you before you can use the Services. This Privacy Policy will be presented to you for review as part of this document, or on a following screen. As part of these Terms and Conditions, you acknowledge that you understand, have read and accept all terms and conditions contained within the JMC Privacy Policy. JMC reserves the right to deny use of the Services to anyone that does not include accurate and/or verifiable information.

10. Operation and Record Retention. JMC and its third party provider reserves complete and sole discretion with respect to the operation of the Service. JMC, through its third party provider, may, among other things withdraw, suspend or discontinue any functionality or feature of the Service. Subject to applicable law, JMC reserves the right to maintain, delete or destroy all communications and materials posted or uploaded to the Service pursuant to its internal record retention and/or destruction policies.

11. Intellectual Property.

(a) Any content available on or through the Service is the property of JMC or its licensors and is protected by copyright, trademark, patent, trade secret and other intellectual property law. We give you permission to display, download, store and print the content only for your personal, non-commercial use. You agree not to reproduce, retransmit, distribute, disseminate, sell, publish, broadcast, or circulate the content received through the Service to anyone. All software and accompanying documentation made available for download from the Service is the copyrighted work of JMC or its licensors. Any copy made of information obtained through the Service must include all applicable copyright notices.

(b) All JMC trade and service names, including, but not limited to "Jupiter Medical Center CareAnywhere", are trademarks of JMC. All other brands and names are the property of their respective owners, including those related to JMC's third party technology platform provider. Nothing contained in the Service should be construed as granting any license or right to use any trademark displayed on this site without the express written permission of JMC or such third-party that may own the trademark.

(c) Subject to the terms of this Agreement, JMC through its third party technology platform provider, hereby grants you a limited, revocable, non-transferable and non-exclusive license to use the software, network facilities, content and documentation on and in the Service to the extent, and only to the extent, necessary to access and use the Service.

(d) The license granted herein does not permit you, and you agree not to: (i) modify, translate, reverse engineer, disassemble, decompile or create derivative works of the Service or allow a third party, whether directly or indirectly (including, but not limited to the direct or indirect use of wizards, agents, bots, or other utilities), to modify, translate, reverse engineer, disassemble, decompile or create derivative works of the Service; or (ii) transfer, distribute, sell, lease, rent, disclose or provide access to the Service to any third party or use the Service to provide service bureau, time sharing or other services to third parties.

12. Disclaimers.

(a) ACCESS TO THE SERVICE AND THE INFORMATION CONTAINED THEREIN IS PROVIDED "AS IS" AND "AS AVAILABLE" WITHOUT ANY WARRANTY OF ANY KIND, EXPRESS OR IMPLIED. TO THE FULLEST EXTENT PERMISSIBLE PURSUANT TO APPLICABLE LAW, JMC AND ITS THIRD PARTY TECHNOLOGY PLATFORM PROVIDER DISCLAIMS ALL WARRANTIES OF ANY KIND, EITHER EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO ANY IMPLIED WARRANTIES OF TITLE, MERCHANTIBILITY, FITNESS FOR A PARTICULAR PURPOSE OR NON-INFRINGEMENT.

(b) WITHOUT LIMITING THE FOREGOING, JMC DOES NOT WARRANT THAT ACCESS TO THE SERVICE WILL BE UNINTERRUPTED OR ERROR-FREE, OR THAT DEFECTS, IF ANY, WILL BE CORRECTED; NOR DOES JMC MAKE ANY REPRESENTATIONS ABOUT THE ACCURACY, RELIABILITY, CURRENCY, QUALITY, COMPLETENESS, USEFULNESS, PERFORMANCE, SECURITY, LEGALITY OR SUITABILITY OF THE SERVICE OR ANY OF THE INFORMATION CONTAINED THEREIN. YOU EXPRESSLY AGREE THAT YOUR USE OF THE SERVICE AND YOUR RELIANCE UPON ANY OF ITS CONTENTS IS AT YOUR SOLE RISK.

(c) YOU SHALL BE SOLELY AND FULLY RESPONSIBLE FOR ANY INACCURATE INFORMATION YOU PROVIDE WHILE USING THE SERVICES. JMC CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR ANY LOSS, DAMAGES OR LIABILITIES ARISING FROM THE FAILURE OF ANY TELECOMMUNICATIONS INFRASTRUCTURE, OR THE INTERNET OR FOR YOUR MISUSE OF THE SERVICES, ANY PROTECTED HEALTH INFORMATION, ADVICE, INFORMATION, OR INSTRUCTIONS ACCESSED OR RECEIVED THROUGH THE SERVICE.

13. Limitations of Liability.

(a) IN THE EVENT YOU EXPERIENCE ANY PROBLEM WITH THE SERVICE, YOU AGREE THAT YOUR SOLE REMEDY IS TO CEASE USING THE SERVICE. UNDER NO CIRCUMSTANCES SHALL JMC, ITS THIRD PARTY TECHNOLOGY PLATFORM PROVIDER OR SUPPLIER, OR ANY THIRD PARTY WHO PROMOTES THE SERVICE OR PROVIDES YOU WITH A LINK TO THE SERVICE BE LIABLE IN ANY WAY FOR YOUR USE OF THE SERVICE INCLUDING, BUT NOT LIMITED TO, ANY ERRORS OR OMISSIONS IN ANY INFORMATION PROVIDED, INFRINGEMENT OF THE INTELLECTUAL PROPERTY RIGHTS OR OTHER RIGHTS OF THIRD PARTIES, OR FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRED AS A RESULT OF YOUR USE OF THE SERVICE.

(b) UNDER NO CIRCUMSTANCES SHALL JMC, ITS THIRD PARTY TECHNOLOGY PLATFORM PROVIDER OR SUPPLIERS OR ANY THIRD PARTY WHO PROMOTES THE SERVICE OR PROVIDES YOU WITH A LINK TO THE SERVICE, BE LIABLE FOR ANY PUNITIVE, EXEMPLARY, CONSEQUENTIAL, INCIDENTAL, INDIRECT OR SPECIAL DAMAGES (INCLUDING, WITHOUT LIMITATION, ANY PERSONAL INJURY, LOST PROFITS, BUSINESS INTERRUPTION, LOSS OF PROGRAMS OR OTHER DATA ON YOUR COMPUTER OR OTHERWISE) ARISING FROM OR IN CONNECTION WITH YOUR USE OF THE SERVICE, WHETHER UNDER A THEORY OF BREACH OF CONTRACT, NEGLIGENCE, STRICT LIABILITYOR OTHERWISE, EVEN IF WE OR THEY HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.

(c) YOU HEREBY RELEASE AND HOLD JMC, ITS THIRD PARTY TECHNOLOGY PLATFORM PROVIDER, SUPPLIERS AND PROVIDERS AND ANY THIRD PARTY WHO PROMOTES THE SERVICE OR PROVIDES YOU WITH A LINK TO THE SERVICE HARMLESS FROM ANY AND ALL CLAIMS, DEMANDS, AND DAMAGES OF EVERY KIND AND NATURE (INCLUDING, WITHOUT LIMITATION, ACTUAL, SPECIAL, INCIDENTAL AND CONSEQUENTIAL), KNOWN AND UNKNOWN, SUSPECTED AND UNSUSPECTED, DISCLOSED AND UNDISCLOSED, ARISING OUT OF OR IN ANY WAY CONNECTED WITH YOUR USE OF THE SERVICE. YOU WAIVE THE PROVISIONS OF ANY STATE OR LOCAL LAW LIMITING OR PROHIBITING A GENERAL RELEASE.

(d) YOU ACKNOWLEDGE AND AGREE THAT JMC'S THIRD PARTY TECHNOLOGY PLATFORM PROVIDER IS NOT ENGAGED IN THE PRACTICE OF MEDICINE AND THAT IT IS NOT DETERMINING APPROPRIATE MEDICAL USE OF THE SERVICE. IT, ITS LICENSORS, SUPPLIER AND ALL THIRD PARTIES WHO PROMOTE THE SERVICE OR PROVIDE YOU WITH A LINK TO THE SERVICE EXPRESSLY DISCLAIMS ANY AND ALL LIABILITY RESULTING FROM THE DELIVERY OF HEALTHCARE VIA THE SERVICE, INCLUDING, BUT NOT LIMITED TO LIABILITY FOR MEDICAL MALPRACTICE. JMC IS THE PARTY PROVIDING THE TELEMEDICINE SERVICE.

14. Indemnification. Without limiting the generality or effect of other provisions of this Agreement, as a condition of use, you agree to indemnify, hold harmless, and defend JMC, its third party technology platform provider, and its parents, subsidiaries, affiliates, licensors, suppliers and their officers, directors, affiliates, subcontractors, agents and employees (collectively, "Indemnified Parties" and each, individually, an "Indemnified Party") against all costs, expenses, liabilities and damages (including reasonable attorney's fees) incurred by any Indemnified Party in connection with any third party claims arising out of your: (i) failure to comply with any applicable laws and regulations; (ii) failure to provide accurate and current information; and (ii) your breach of any of your obligations set forth in this Agreement.

15. Electronic Contracting and Notices. Your assent to the terms of this Agreement by clicking the "AGREE" checkbox.

PRIVACY POLICY

Effective July 11, 2017

The following is a summary of our online Privacy Policy (at times herein, “Agreement”). By visiting JMC's telemedicine Service, you are accepting the terms and conditions of this Privacy Policy.

INFORMATION OBTAINED

(1) Information You Give Us. JMC receives and stores information you enter or provide while using the Service. We use the information you provide for such purposes as:

(2) Automatic Information. JMC receives and stores certain types of information whenever you interact with us. For example, we may use "cookies" and we may obtain certain types of information when you access the Service. Various companies offer utilities designed to help you visit websites anonymously. Although we will not be able to provide you with the Services if we cannot recognize you, we want you to know these tools exist. Should you disable our ability to recognize you, we may not be able to confirm your identity, which will limit your participation with JMC. Examples include, but are not limited to, Internet Protocol (IP) address used to connect your computer to the internet; login; email address; password; time and date of visit; computer and connection information; cookie number; the phone number you used to call our company.

During some visits we may use software tools such as SQL, Java, Analytics, or JavaScript to measure and collect session information, including page response times, download errors, length of visits to certain pages, page interaction information (such as scrolling, clicks, and mouse-overs), and methods used to browse away from the page. Much of this information is kept for purposes of protecting and tracing transactions should the need arise to intervene as in the case of stolen identities or credit card fraud.

OUR DISCLAIMERS

We release account and other personal information when we think it is appropriate to comply with the law; enforce or apply our Terms of Use or Privacy Policy and other agreements; or protect the rights, property, or safety of JMC, our users, or others. This includes exchanging information with other companies and organizations for fraud protection and credit risk reduction. This does not include selling, renting, sharing, or otherwise disclosing personally identifiable information from customers for commercial purposes in violation of the commitments set forth herein.

INFORMATION SECURITY

(1) We work to protect the security of your information during transmission by software which encrypts information you input.

(2) For certain Services that require a fee, we will collect credit card or billing/payment account information which we maintain in encrypted form on secure servers. This information is transmitted through the Internet using Secure Socket Layers (SSL) technology. SSL technology causes your browser to encrypt your entered information before transmitting it to our secure server. SSL technology, an industry standard, is designed to prevent someone other than operators of the Service platform from capturing and viewing your personal information.

(3) It is important for you to protect against unauthorized access to the Services. Be sure to sign off when finished using the Services. If you visit a library to access the Services or are using a computer which has multiple users, please remember to close your session by properly logging out. Then close the browser.

Condition of Use Privacy Policy:

If you choose to visit Jupiter Medical Center CareAnywhere, your visit and any dispute over privacy is subject to this Agreement, including limitations on damages, arbitration of disputes, and application of the law of the state of Florida. If you have any concern about privacy while using this Service, please contact us with a thorough description, and we will try to resolve the issue.

Changes to the Privacy Policy:

Since JMC Telemedicine changes constantly, our online Privacy Notice and Conditions of Use may also change. 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 web site.

NOTICE OF HIPAA PRIVACY PRACTICES

Protected Health Information ("PHI") includes demographic and medical information that concerns your past, present, or future physical and/or mental health. PHI contains specific information that identifies you or can be used to identify you.

Your Information. Your Rights. Our Responsibilities. Our Disclaimers.

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.

SUMMARY

(1) Your Rights

You have the right to:

(2) Your Choices

You have some choices in the way that we use and share information with family and friends about your condition.

(3) 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
  • Work with a medical examiner or funeral director
  • Address workers’ compensation, law enforcement, and other government requests
  • Respond to lawsuits and legal actions

We will not market or sell your health information.

YOUR RIGHTS

When it comes to your protected health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

(1) Get an electronic or paper copy of your medical record

(2) Ask us to correct your medical record

(3) Request different means of communication

(4) Ask us to limit what we use or share

(5) Know who has seen your information

(7) Choose someone to act for you

(8) File a complaint if you feel your rights are violated

www.hhs.gov/ocr/privacy/hipaa /complaints/

YOUR CHOICES

You can tell us your choices about what we share with your family, close friends, or others involved in your care. If you have a clear preference for how we share your information, talk to us. Tell us what you want us to do, and we will follow your instructions.

If you are not able to tell us your preference, for example if you are unconscious, we may 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.

OUR USES AND DISCLOSURES

(1) How do we typically use or share your protected health information?

We typically use or share your health information, including but not limited to, the following ways.

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury may ask another doctor who has previously provided your services about your overall health condition.

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We may use health information about you to manage your treatment and services and to contact you regarding results, findings, referrals, and/or treatment options.

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We may give information about you to your health insurance plan so it will pay for services you receive.

(2) How else can we use or share your protected health information?

We are allowed or required to share your information in other ways (without your written authorization) – 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.

We can share PHI about you for certain situations such as:

We can use or share your de-identified information for health research. De-identified information means information which does not reveal your identity.

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 are complying with federal privacy law.

We can share health information about you with organ procurement organizations.

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

We can use or share health information about you:

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

OUR RESPONSIBILITIES

(1) We are required by law to maintain the privacy and security of your protected health information.

(2) We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

(3) We must follow the duties and privacy practices described in this notice and give you a copy of it.

(4) 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.

(5) W must notify you about how we protect your PHI.

(6) We may only use and/or disclose PHI as described in this Notice.

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 web site.

Privacy Officer Contact Information:

Contact: Nancy Blaszkowski - (561) 232-8475 or NBlaszkowski@jupitermed.com

References:

"Standards for the Privacy of Individually Identifiable Health Information; Final Rule." 45 CFR Parts 160 through 164. Federal Register 65, no. 250 (December 28, 2000).

"Standards for the Privacy of Individually Identifiable Health Information; Final Rule." 45 CFR Parts 160 through 164. Federal Register, Volume 67 (August 14, 2002).

HHS, Modification to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information and Nondiscrimination Act; Other Modification to the HIPAA Rules, 78 Fed. Reg. 5566 (January 25, 2013).

THIS CONCLUDES OUR TERMS OF USE AND PRIVACY POLICY.


PATIENT ACKNOWLEDGMENT AND CONSENT

BY CLICKING THE APPLICABLE "AGREE" CHECKBOX BELOW, I AM INDICATING THAT I HAVE REVIEWED, ACKNOWLEDGED AND CONSENT TO THE TERMS OF THIS PATIENT ACKNOWLEDGEMENT AND CONSENT (AT TIMES, THIS “AGREEMENT”) DESCRIBED BELOW:

1. Consent to Healthcare Services: I am requesting that health care services be provided to me (or my minor child or the patient named below) by JMC through this telemedicine platform (“Service(s)”). I voluntarily consent to all medical treatment and health care-related services that the caregivers at JMC consider to be necessary for me (or the patient named below). These services may include diagnostic, therapeutic, imaging, and laboratory services and testing. If I want any testing to be performed anonymously (such as, for example, HIV testing), I will tell my JMC caregiver. My blood may be used to perform routine quality assurance testing. I am aware that the practice of medicine and surgery is not an exact science; no guarantees have been made to me about the results of treatments or examinations.

2. Possible Risks of Telemedicine. As with any medical procedure or services, there are potential risks associated with the use of telemedicine Services. JMC believes the likelihood of these risks materializing is low, but cannot guarantee that such risks will not occur. I acknowledge and accept that these risks may include, but not be limited to, to following:

(a) Delays in medical evaluation and consultation or treatment may occur due to the deficiencies or failures of the equipment used in the telemedicine process (in some instances information transmitted may be of insufficient quality to allow for appropriate medical or health care decision making by the Provider (i.e., poor resolution images, etc.));

(b) Security protocols could fail, causing a breach of privacy or personal medical information;

(c) Lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other negative outcomes; and/or

(d) Such other medical risks (including, but not limited to, misdiagnosis) which may arise as a result of a medical evaluation which is performed online via a telemedicine platform, rather than in person.

3. Acceptance of Risks. By using the Services, you are expressly accepting the possible risks of telemedicine described above, and you acknowledge that you understand and agree with the following:

(a) While you may expect the anticipated benefits from the use of telemedicine in your care, there is not guarantee or assurance that you will receive the anticipated results;

(b) The laws that protect the privacy and security of health information apply to telemedicine and you have received JMC's privacy practices which describe these protection(s) in more detail;

(c) You are fully responsible for payment regardless of whether the Provider who consults with and/or treats you via telemedicine requires you to follow up with a health care practitioner for an in-office visit; and

(d) You understand that your Provider, in his or her sole discretion and professional judgment, may determine that telemedicine services are not appropriate for some or all of your treatment needs and, accordingly, may elect not to provide telemedicine services to you through the telemedicine platform.

4. Financial Responsibility:

(a) I agree to the following:

i. Subject to applicable law and the terms and conditions of any applicable contract between JMC and a third-party payer, and in consideration of all health care services rendered or about to be rendered to me, I agree to be financially responsible and obligated to pay JMC for any balance not paid under the "Assignment of Benefits/Third Party Payers" Paragraph 5 below; and


ii. Subject to applicable law, and in consideration of all health care services rendered or about to be rendered to me, I agree to be financially responsible and obligated to pay JMC for the patient balances due; and

iii. I authorize the JMC and all clinical providers who have provided care to me, along with any billing services, collection agencies or other agents who may work on their behalf, to contact me on my cell and/or other phone including through the use of automatic telephone dialing system or other computer assisted technology.

5. Assignment of Benefits/ Third-Party Payers: In consideration of all health care services rendered or about to be rendered to me, I hereby assign to JMC all right, title, and interest in and to any third-party benefits due from any and all insurance policies and/or responsible third-party payers of an amount not exceeding JMC's regular and customary charges for the healthcare services rendered. I authorize such payments from applicable insurance carriers, third party payers, and other third-parties. A list of usual and customary charges is available upon request. I consent to any request for review or appeal by JMC to challenge a determination of benefits made by a third-party payer. Except as required by law, I assume responsibility for determining in advance whether the services provided are covered by insurance or other third party payer.

6. Uses and Disclosures of Health Information:

(a) I have received JMC's Privacy Policy. The Privacy Policy explains how JMC may use and disclose confidential health information that identifies me. I consent to let JMC use and disclose health information about me as described in the Privacy Policy. In doing so I consent to the release of my health information and financial account information to all third-party payers and/or their agents that are identified by JMC, its billing agents, collection agents, attorneys, consultants, and/or other agents that represent JMC or provide assistance to JMC for the purposes of securing payment from all parties who are potentially liable for payment for my health care, including for substance abuse, psychiatric care, or HIV, if applicable. I can revoke my consent in writing at any time except to the extent that JMC has already relied on my consent.

(b) I understand that telemedicine may involve electronic communication of my personal medical information (i) to or from medical practitioners who may be located in other areas of Florida, or (ii) from JMC to me (or vice versa). I consent to receive secure email and/or other electronic communications that may contain my protected health information from JMC. I further accept the risk that my personal Internet service provider may not provide adequate security to prevent theft or inadvertent disclosure of my protected health information.

(c) I understand that my healthcare information may be shared with other individuals for treatment, payment and healthcare operations purposes. Psychotherapy notes are maintained by clinicians but are not shared with others, while billing codes and encounter summaries are shared with others and with me. If I obtain psychotherapy from JMC, with proper signed authorization, I understand that my therapist has the right to limit the information provided to me if in my therapist's professional judgment sharing the information with me would be harmful to me or to others.

7. Other Conditions of Use:

(a) Governing Law. This Agreement shall be governed by the laws of the State of Florida without regard to its rules on conflicts or choice of law, or your domicile, residence or physical location. You agree that any legal action or proceedings between you and JMC for any purpose concerning this Agreement or the parties' obligations hereunder shall be brought exclusively in federal or state court of competent jurisdiction sitting in Palm Beach County, Florida. You hereby consent to the exclusive jurisdiction of the courts of the State of Florida for the resolution of any dispute based upon or relating to this Agreement.

(b) Entire Agreement. This Agreement constitutes the sole Agreement between you and JMC relating to your use and our provision of the Service and the subject matter hereof, and any representations, statements or inducements, oral or written, which are not contained in this Agreement shall not bind either you or JMC. We may modify this Agreement at any time. Any modification made to this Agreement will be effective immediately upon posting to this Service. By accessing or using the Services, you agree to be bound by all of the terms and conditions of this Agreement as posted on the Service date at the time of your access or use. You agree to review the Agreement posted on the Service each time you use the Service so that you are aware of any modification made to this Agreement.

(c) Severability. Any of the terms of this Agreement which are determined to be invalid or unenforceable shall be ineffective to the extent of such invalidity or unenforceability, without rendering invalid or unenforceable any of the remaining terms of this Agreement or affecting the validity or enforceability of the Agreement as a whole. In any dispute between you and JMC relating to the Service, the prevailing party shall be entitled to reasonable attorneys' fees, costs, and expenses.

(d) No Waiver. Failure to insist on performance of any of the terms of the Agreement will not operate as a waiver of any subsequent default. No waiver by JMC of any right under this Agreement will be deemed to be either a waiver of any other right or provision or a waiver of that same right or provision at any other time.

(e) Assignment. You may not assign, transfer or delegate your rights or obligations hereunder, in whole or in part. This Agreement shall be binding upon and inure to the benefit of each of the parties and the parties' respective successors and permitted assigns.

(f) Waiver of Trial by Jury. THE PARTIES HERETO HEREBY WAIVE TRIAL BY JURY IN ANY LITIGATION, SUIT OR PROCEEDING, IN ANY COURT WITH RESPECT TO, IN CONJUNCTION WITH, OR ARISING OUT OF THESE TERMS OF USE OR THE PRIVACY POLICY OR THE VALIDITY, PROTECTION, INTERPRETATION, COLLECTION OR ENFORCEMENT THEREOF, AND/OR PERFORMANCE OF ANY OF THE OBLIGATIONS OR SERVICES HEREUNDER OR THEREUNDER; PROVIDED, HOWEVER, THAT WITH RESPECT TO ANY COMPULSORY COUNTERCLAIM (I.E., A CLAIM BY A PARTY HERETO AGAINST ANOTHER PARTY WHICH, IF NOT BROUGHT IN SUCH ACTION, WOULD RESULT IN THE FIRST PARTY BEING FOREVER BARRED FROM BRINGING SUCH CLAIM), A PARTY HERETO SHALL HAVE THE RIGHT TO RAISE SUCH COMPULSORY COUNTERCLAIM IN ANY SUCH LITIGATION, SUIT OR PROCEEDING, WHETHER OR NOT IT IS BEING TRIED BY A JURY.

(g) Comments, Suggestions, and Submissions. JMC welcomes comments, suggestions and submissions by its Customers. Any comments, suggestions and submissions made by Customers, including but not limited to, messages, notes, feedback, artwork, communications, computer code or creative materials provided to JMC shall become the exclusive property of JMC. At the time the comment, suggestion, and/or submission is made it shall act as a full assignment to JMC of all rights whatsoever (copyright, patentability, and intellectual property). JMC shall have the right to use said comment, suggestion and/or submission as its own for all legal purposes including, but not limited to, reproduction, disclosure, publishing, distribution and the like without any compensation to Customer. This section shall not include any personal information submitted by Customer that would be included as part of the Health Information Portability and Accountability Act of 1996. Please submit comments, suggestions and submission to Customer Service at the end of your visit.

THIS CONCLUDES OUR PATIENT ACKNOWLEDGEMENT AND CONSENT.